Fidelis Care 2011 Formulary (List of Covered Drugs)

Fidelis Care
2011 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION

ABOUT THE DRUGS WE COVER IN THIS PLAN
Note to existing members: This formulary has changed since last year. Please review this
document to make sure that it still contains the drugs you take.
Fidelis Care is a Medicare Advantage organization with a Medicare contract.

This information is available in a different format, including Spanish, large print, and audio tapes.
Please call Member Services at the number listed above if you need plan information in another
format or language.
Esta informacin est disponible en un formato diferente, incluyendo en espaol, letras grandes, y
en cintas de audio. Por favor llame a Servicio al Miembro al nmero que aparece arriba si necesita
informacin del plan en otro formato o idioma.
H3328 FC 10106 File & Use 09082010

1
What is the Fidelis Care Formulary?

A formulary is a list of covered drugs selected by Fidelis Care in consultation with a team of
health care providers, which represents the prescription therapies believed to be a necessary part of
a quality treatment program. Fidelis Care will generally cover the drugs listed in our formulary as
long as the drug is medically necessary, the prescription is filled at a Fidelis Care network
pharmacy, and other plan rules are followed. For more information on how to fill your
prescriptions, please review your Evidence of Coverage.
Can the Formulary change?

Generally, if you are taking a drug on our 2010 formulary that was covered at the beginning of the
year, we will not discontinue or reduce coverage of the drug during the 2011 coverage year except
when a new, less expensive generic drug becomes available or when new adverse information
about the safety or effectiveness of a drug is released. Other types of formulary changes, such as
removing a drug from our formulary, will not affect members who are currently taking the drug. It
will remain available at the same cost-sharing for those members taking it for the remainder of the
coverage year. We feel it is important that you have continued access for the remainder of the
coverage year to the formulary drugs that were available when you chose our plan, except for
cases in which you can save additional money or we can ensure your safety.
If we remove drugs from our formulary, add prior authorization, quantity limits and/or step
therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected
members of the change at least 60 days before the change becomes effective, or at the time the
member requests a refill of the drug, at which time the member will receive a 60-day supply of the
drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the
drugs manufacturer removes the drug from the market, we will immediately remove the drug
from our formulary and provide notice to members who take the drug. The enclosed formulary is
current as September 1, 2010. To get updated information about the drugs covered by Fidelis Care,
please visit our Web site at www.fideliscare.org or call Member Services at 1-800-247-1447, from
8:00 AM to 8:00 PM seven days a week, November 15th through March 1st. From March 2nd to
November 14th Member Services will be available from 8:00 AM to 8:00 PM Monday through
Friday. TTY/TDD users should call 1-800-695-8544.
We will mail you updated information about our formulary in the event that there are mid-year
non-maintenance formulary changes.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 6. The drugs in this formulary are grouped into categories
depending on the type of medical conditions that they are used to treat. For example, drugs used to
treat a heart condition are listed under the category, Cardiovascular. If you know what your drug is
used for, look for the category name in the list that begins on page 6. Then look under the category
name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that
begins on page 40. The Index provides an alphabetical list of all of the drugs included in this
document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and
find your drug. Next to your drug, you will see the page number where you can find coverage
information. Turn to the page listed in the Index and find the name of your drug in the first column
of the list.
What are generic drugs?

Fidelis Care covers both brand-name drugs and generic drugs. A generic drug is approved by the
FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost
less than brand-name drugs.
Are there any restrictions on my coverage?

Some covered drugs may have additional requirements or limits on coverage. These requirements
and limits may include:
Prior Authorization: Fidelis Care requires you or your physician to get prior authorization for
certain drugs. This means that you will need to get approval from Fidelis Care before you fill
your prescriptions. If you dont get approval, Fidelis Care may not cover the drug.
Quantity Limits: For certain drugs, Fidelis Care limits the amount of the drug that we will
cover. For example, Fidelis Care provides 14 capsules per prescription for Zaleplon. This
maybe in addition to a standard one month or three-month supply.
You can find out if your drug has any additional requirements or limits by looking in the
formulary that begins on page 6. You can also get more information about the restrictions applied
to specific covered drugs by visiting out Web site at www.fideliscare.org.
You can ask Fidelis Care to make an exception to these restrictions or limits. See the section,
How do I request an exception to the Fidelis Cares formulary? on page 4 for information about
how to request an exception.
What are over-the-counter (OTC) drugs?
OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription
Drug Plan. Fidelis Care pays for certain OTC drugs. Fidelis Care will provide these OTC drugs at
no cost to you. The cost to Fidelis Care of these OTC drugs will not count toward your total drug
costs.
What if my drug is not on the Formulary?
If your drug is not included in this formulary, you should first contact Member Services and ask if
your drug is not covered. If you learn that Fidelis Care does not cover your drug, you have two
options:
You can ask Member Services for a list of similar drugs that are covered by Fidelis Care. When
you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is
covered by Fidelis Care.
You can ask Fidelis Care to make an exception and cover your drug. See below for information
about how to request an exception.
How do I request an exception to the Fidelis Care Formulary?

You can ask Fidelis Care to make an exception to our coverage rules. There are several types of
exceptions that you can ask us to make.
You can ask us to cover your drug even if it is not on our formulary.
You can ask us to waive coverage restrictions or limits on your drug. For example, for certain
drugs, Fidelis Care limits the amount of the drug that we will cover. If your drug has a quantity
limit, you can ask us to waive the limit and cover more.
You can ask us to provide a higher level of coverage for your drug. If your drug is contained in
our Non-Preferred Brand tier, you can ask us to cover it at the cost-sharing amount that applies
to drugs in the Generic tier instead. This would lower the amount you must pay for your drug.
Please note, if we grant your request to cover a drug that is not on our formulary, you may not
ask us to provide a higher level of coverage for the drug.
Generally, Fidelis Care will only approve your request for an exception if the alternative drug is
included on the plans formulary, is the lower-tiered drug, or additional utilization restrictions
would not be as effective in treating your condition and/or would cause you to have adverse
medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering, or
utilization restriction exception. When you are requesting a formulary, tiering, or utilization
restriction exception you should submit a statement from your physician supporting your
request. Generally, we must make our decision within 72 hours of getting your prescribing
physicians supporting statement. You can request an expedited (fast) exception if you or your
doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision.
If your request to expedite is granted, we must give you a decision no later than 24 hours after we
get your prescribing physicians supporting statement.
What do I do before I can talk to my doctor about changing my drugs or requesting an

exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary.
Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For
example, you may need a prior authorization from us before you can fill your prescription. You
should talk to your doctor to decide if you should switch to an appropriate drug that we cover or
request a formulary exception so that we will cover the drug you take. While you talk to your
doctor to determine the right course of action for you, we may cover your drug in certain cases
during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited,
we will cover a temporary 30-day supply (unless you have a prescription written for fewer days)
when you go to a network pharmacy. After your first 30-day supply, we will not pay for these
drugs, even if you have been a member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will cover a temporary 34-day transition
supply (unless you have a prescription written for fewer days). We will cover more than one refill
of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on
our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of
membership in our plan, we will cover a 34-day emergency supply of that drug (unless you have a
prescription for fewer days) while you pursue a formulary exception.
4
For more information

For more detailed information about your Fidelis Care prescription drug coverage, please review
your Evidence of Coverage and other plan materials.
If you have questions about Fidelis Medicare Advantage, Fidelis Medicare Advantage Flex Plan,
Fidelis Dual Advantage and Fidelis Dual Advantage Flex Plan, please call Member Services at 1800-247-1447, from 8:00 AM to 8:00 PM seven days a week, November 15th through March 1st.
From March 2nd to November 14th Member Services will be available from 8:00 AM to 8:00 PM
Monday through Friday. TTY/TDD users should call 1-800-695-8544 or visit
www.fideliscare.org. If you have general questions about Medicare prescription drug coverage,
please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week.
TTY/TDD users should call 1-877-486-2048. Or, visit www.medicare.gov.
Fidelis Cares Formulary

The formulary that begins on the next page provides coverage information about some of the drugs
covered by Fidelis Care. If you have trouble finding your drug in the list, turn to the Index that
begins on page 40.
The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g.,
PENCILLAMINE) and generic drugs are listed in lower-case italics (e.g., ampicillin).
The information in the Notes column tells you if Fidelis Care has any special requirements for
coverage of your drug. For example, PA means prior authorization is required. (This means that
you will need to get approval from Fidelis Care before you fill your prescriptions); QL means
that quantity limits apply (Fidelis Care limits the amount of the drug that Fidelis Care will cover);
B/D means that the drug is covered under Part B and Part D of Medicare (Fidelis Care will
determine whether a particular prescription is covered under Part B or Part D).
CY2011_5T_PLUS_Jan
Drug
Tier
Notes
ANALGESICS
COX-2 INHIBITORS
CELEBREX
PA
GOUT
allopurinol
allopurinol sodium
colchicine w/ probenecid
COLCRYS
probenecid
ULORIC
1
2
2
4
2
3
QL (60 tabs / 25 days)
NARCOTIC ANALGESICS
acetaminophen w/ codeine
butalbital-acetaminophen-caffeine w/ codeine
butalbital-aspirin-caffeine w/cod
butorphanol tartrate
hydrocodone-acetaminophen
2
2
2
2
2
NARCOTIC ANALGESICS, CII

AVINZA
DILAUDID-5
fentanyl
4
3
2
fentanyl citrate
hydromorphone hcl 10mg/ml
hydromorphone hcl 2mg, 4mg, 8mg
KADIAN
methadone hcl 10mg, 5mg
methadone hcl 10mg/ml
METHADONE HCL 10mg/5ml, 5mg/5ml
morphine sulfate .5mg/ml, 1mg/ml, 5mg/ml
morphine sulfate 100mg, 15mg, 30mg, 60mg
morphine sulfate 15mg, 30mg
morphine sulfate 200mg
MORPHINE SULFATE 10mg/5ml, 20mg/5ml
OPANA ER
oxycodone hcl
oxycodone w/ acetaminophen
oxycodone w/ aspirin
OXYCONTIN
ROXICET
2
2
2
3
2
2
3
2
2
2
2
3
4
2
2
2
3
3
QL (60 ea / 25 days)
QL (10 ea / 25 days);
patch
B/D; injection
B/D
B/D
QL (120 ea / 25 days)
QL (120 ea / 25 days)
solution
NON-NARCOTIC ANALGESICS
tramadol hcl
tramadol-acetaminophen
2
2
NSAIDS
diclofenac potassium
Drug
diclofenac sodium
diflunisal
etodolac
flurbiprofen
ibuprofen
INDOCIN
indomethacin
ketoprofen
ketorolac tromethamine
meloxicam
nabumetone
naproxen 250mg, 375mg
naproxen 125mg/5ml, 375mg, 500mg
naproxen sodium
oxaprozin
piroxicam
sulindac
tolmetin sodium
VOLTAREN
Tier
Notes
2
2
2
1
1
3
suspension
2
2
2
2
2
1
2
2
2
1
2
2
3
gel
ANESTHETICS
LOCAL ANESTHETICS
lidocaine hcl (local anesth.)
ANTI-INFECTIVES
ANTIBACTERIALS
amikacin sulfate
amoxicillin
amoxicillin & pot clavulanate
ampicillin 250mg, 500mg
ampicillin 125mg/5ml, 250mg/5ml
ampicillin & sulbactam sodium
ampicillin sodium
AVELOX
AVELOX ABC PACK
azithromycin
BICILLIN C-R
BICILLIN L-A
CEDAX
cefaclor
CEFACLOR ER
cefadroxil
cefazolin sodium 1gm, 20gm, 500mg
CEFAZOLIN SODIUM
cefdinir
cefepime hcl
cefotaxime sodium
cefoxitin sodium
2
1
2
1
2
2
2
3
3
2
3
3
4
2
3
2
2
3
2
2
2
2
Drug
cefpodoxime proxetil
cefprozil
ceftriaxone sodium
cefuroxime axetil
cefuroxime sodium
CEFUROXIME/DEXTROSE
cephalexin 250mg, 500mg
cephalexin 125mg/5ml, 250mg/5ml
CIPRO
ciprofloxacin
ciprofloxacin hcl 250mg, 500mg, 750mg
ciprofloxacin hcl 100mg
ciprofloxacin-ciprofloxacin hcl
clarithromycin
dicloxacillin sodium
doxycycline (monohydrate)
doxycycline hyclate 100mg, 50mg
doxycycline hyclate 100mg
doxycycline hyclate 20mg
ERYPED 200
ERYTHROCIN LACTOBIONATE
erythromycin base
erythromycin ethylsuccinate
erythromycin stearate
gentamicin in saline
gentamicin sulfate
LEVAQUIN
minocycline hcl
nafcillin sodium
neomycin sulfate
paromomycin sulfate
penicillin g potassium
PENICILLIN G PROCAINE
penicillin v potassium
piperacillin sodium-tazobactam sodium
streptomycin sulfate
SULFADIAZINE
SUPRAX
tetracycline hcl
tobramycin sulfate
Tier
Notes
2
2
2
2
2
3
1
2
3
suspension
2
1
2
2
ext rel
2
2
2
1
2
injection
2
3
3
1
1
1
2
2
4
2
2
2
2
2
3
1
2
2
3
4
1
2
ANTIFUNGALS
amphotericin b
ANCOBON
CANCIDAS
clotrimazole
fluconazole 150mg
2
3
3
2
1
B/D
Drug
fluconazole 100mg, 10mg/ml, 200mg,
40mg/ml, 50mg
fluconazole in dextrose
GRIS-PEG
griseofulvin microsize
itraconazole
ketoconazole
NOXAFIL
nystatin
SPORANOX
terbinafine hcl
VFEND
VFEND IV
Tier
2
2
3
2
2
2
5
2
4
2
5
5
Notes
PA
PA
ANTIMALARIALS
chloroquine phosphate
COARTEM
DARAPRIM
MALARONE
mefloquine hcl
QUALAQUIN
2
4
3
3
2
4
ANTIRETROVIRAL AGENTS
APTIVUS
ATRIPLA
COMBIVIR
CRIXIVAN
didanosine
EMTRIVA
EPIVIR
EPZICOM
FUZEON
INTELENCE
INVIRASE
ISENTRESS
KALETRA
LEXIVA
NORVIR
PREZISTA 75mg
PREZISTA 400mg, 600mg
RESCRIPTOR
RETROVIR IV INFUSION
REYATAZ
SELZENTRY
stavudine
SUSTIVA
TRIZIVIR
TRUVADA
VIDEX
3
5
3
3
2
3
3
3
5
3
3
5
3
3
3
3
5
3
3
3
5
2
3
3
3
3
Drug
VIRACEPT
VIRAMUNE
VIREAD
ZIAGEN
zidovudine
Tier
3
3
3
3
2
Notes
ANTITUBERCULAR AGENTS
CAPASTAT SULFATE
ethambutol hcl
isoniazid 100mg, 300mg
isoniazid 100mg/ml, 50mg/5ml
MYCOBUTIN
PASER
PRIFTIN
pyrazinamide
rifampin
SEROMYCIN
TRECATOR
4
2
1
2
3
4
4
2
2
4
4
ANTIVIRALS
acyclovir
acyclovir sodium
BARACLUDE
EPIVIR HBV
famciclovir
ganciclovir 250mg
GANCICLOVIR 500mg
HEPSERA
REBETOL
RELENZA DISKHALER
RIBAPAK
RIBASPHERE
RIBAVIRIN
ribavirin (hepatitis c)
rimantadine hydrochloride
TAMIFLU
TYZEKA
valacyclovir hcl
VALCYTE
2
2
3
3
2
2
5
5
5
3
5
5
5
2
2
3
3
2
5
PA
PA
PA
PA
PA
PA; 200mg tablet
PA
MISCELLANEOUS
ALBENZA
ALINIA 100mg/5ml
ALINIA 500mg
CLEOCIN 75mg
CLEOCIN PEDIATRIC GRANULE
clindamycin hcl
clindamycin phosphate
colistimethate sodium
3
3
3
3
3
2
2
2
QL (3 bottles / 25 days)
B/D
10
Drug
CUBICIN
dapsone
erythromycin-sulfisoxazole
FURADANTIN
INVANZ
MACRODANTIN
mebendazole
MEPRON
metronidazole 250mg, 500mg
metronidazole 375mg
metronidazole in nacl
nitrofurantoin macrocrystal
nitrofurantoin monohyd macro
PRIMAXIN I.M.
PRIMAXIN IV
sulfamethoxazole-trimethoprim
sulfamethoxazole-trimethoprim
TINDAMAX
trimethoprim
TYGACIL
VANCOCIN HCL
vancomycin hcl
VANCOMYCIN HCL ISO-OSMOTI
ZYVOX
Tier
5
2
2
4
3
3
2
5
1
2
2
2
2
3
3
1
tablet
2
3
1
5
5
2
3
5
Notes
ANTINEOPLASTIC AGENTS
ALKYLATING AGENTS
BICNU
BUSULFEX
CEENU
cyclophosphamide
dacarbazine
EMCYT
HEXALEN
IFEX
IFOSFAMIDE
LEUKERAN
melphalan hcl
MUSTARGEN
TREANDA
3
3
3
2
2
3
5
3
5
3
2
3
5
B/D
B/D
2
5
2
5
2
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
ANTHRACYCLINES
daunorubicin hcl
DOXIL
doxorubicin hcl
EPIRUBICIN HCL
idarubicin hcl
ANTIBIOTICS
11
Drug
bleomycin sulfate
COSMEGEN
mitomycin
Tier
2
B/D
3
B/D
2
B/D
Notes
ANTIMETABOLITES
ALIMTA
cytarabine
fluorouracil
GEMZAR
mercaptopurine
methotrexate sodium 1gm, 25mg/ml
pentostatin
TABLOID
VIDAZA
5
2
2
3
2
2
2
3
5
B/D
B/D
B/D
B/D
2
5
B/D
B/D
3
2
2
B/D
B/D
B/D
5
3
5
5
3
5
5
5
B/D
B/D
B/D
B/D
B/D
B/D
PA
B/D
B/D
B/D
B/D
ANTIMITOTIC, TAXOIDS
paclitaxel
TAXOTERE
ANTIMITOTIC, VINCA ALKALOIDS

VINBLASTINE SULFATE
vincristine sulfate
vinorelbine tartrate
BIOLOGIC RESPONSE MODIFIERS

AVASTIN
CAMPATH
HERCEPTIN
ISTODAX
ONTAK
PROLEUKIN
RITUXAN
VELCADE
HORMONAL ANTINEOPLASTIC AGENTS

ARIMIDEX
AROMASIN
bicalutamide
DEPO-PROVERA
FARESTON
FASLODEX
FEMARA
flutamide
leuprolide acetate
LUPRON DEPOT 11.25mg, 3.75mg
LUPRON DEPOT 22.5mg, 30mg, 7.5mg
LUPRON DEPOT-PED
MEGACE ES
megestrol acetate
NILANDRON
tamoxifen citrate
3
3
2
3
3
5
3
2
2
3
5
5
3
2
3
2
B/D
B/D
PA
PA
PA
PA
12
Drug
TRELSTAR DEPOT MIXJECT
TRELSTAR LA MIXJECT
Tier
3
B/D
3
B/D
Notes
KINASE INHIBITORS
AFINITOR
GLEEVEC
NEXAVAR
SPRYCEL
SUTENT
TARCEVA
TASIGNA
TYKERB
VOTRIENT
5
5
5
5
5
5
5
5
5
MISCELLANEOUS
DROXIA
ELSPAR
hydroxyurea
IRINOTECAN
LYSODREN
MATULANE
MITOXANTRONE HCL
ONCASPAR
PHOTOFRIN
TARGRETIN 75mg
TRETINOIN 10mg
TRISENOX
ZOLINZA
3
3
2
5
3
3
5
3
3
5
5
3
5
B/D
B/D
B/D
B/D
B/D
capsule
B/D
NUCLEOSIDE ANALOGS
cladribine
FLUDARABINE PHOSPHATE
2
5
B/D
B/D
2
2
5
B/D
B/D
B/D
2
2
5
2
2
2
3
2
3
B/D
B/D
B/D
B/D
B/D
2
3
B/D
B/D; injection
PLATINUM COORDINATION COMPLEX

carboplatin
cisplatin
OXALIPLATIN
PROTECTIVE AGENTS
amifostine crystalline
dexrazoxane
ELITEK
ifosfamide & mesna
leucovorin calcium 100mg, 350mg
leucovorin calcium 25mg, 5mg
LEUCOVORIN CALCIUM 10mg, 15mg
mesna
MESNEX
B/D
TOPOISOMERASE INHIBITORS
etoposide
HYCAMTIN
13
Drug
Tier
Notes
CARDIOVASCULAR
ACE INHIBITOR COMBINATIONS
amlodipine besylate-benazepril hcl
benazepril & hydrochlorothiazide
captopril & hydrochlorothiazide
enalapril maleate & hydrochlorothiazide
fosinopril sodium & hydrochlorothiazide
lisinopril & hydrochlorothiazide
LOTREL
moexipril-hydrochlorothiazide
quinapril-hydrochlorothiazide
TARKA
trandolapril-verapamil hcl
2
2
2
2
2
2
3
2
2
4
2
5-40mg, 10-40mg
ACE INHIBITORS
benazepril hcl
captopril
enalapril maleate
fosinopril sodium
lisinopril
moexipril hcl
perindopril erbumine
quinapril hcl
ramipril
trandolapril
1
1
1
2
2
2
2
2
2
2
ADRENOLYTICS, CENTRAL
clonidine hcl .1mg, .2mg, .3mg
clonidine hcl .1mg/24hr, .2mg/24hr,
.3mg/24hr
guanfacine hcl
1
2
2
ALDOSTERONE RECEPTOR ANTAGONISTS

eplerenone
spironolactone
2
2
ALPHA BLOCKERS
doxazosin mesylate
prazosin hcl
terazosin hcl
1
2
2
ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS

ATACAND HCT
DIOVAN HCT
EXFORGE
EXFORGE HCT
losartan potassium & hydrochlorothiazide
MICARDIS HCT
TEVETEN HCT
VALTURNA
4
3
3
3
2
4
4
3
ANGIOTENSIN II RECEPTOR ANTAGONISTS

14
Drug
ATACAND
BENICAR
BENICAR HCT
DIOVAN
losartan potassium
MICARDIS
TEVETEN
Tier
4
3
3
3
2
4
4
Notes
ANTIARRHYTHMICS
amiodarone hcl 200mg, 400mg
amiodarone hcl 50mg/ml
disopyramide phosphate
flecainide acetate
mexiletine hcl
MULTAQ
NORPACE CR
PACERONE
propafenone hcl
quinidine gluconate
quinidine sulfate
RYTHMOL SR
sotalol hcl
TIKOSYN
2
2
2
2
2
3
3
3
2
2
2
3
2
3
B/D
ANTILIPEMICS
ADVICOR
ALTOPREV
ANTARA
cholestyramine light
colestipol hcl
CRESTOR
fenofibrate
fenofibrate micronized
gemfibrozil
LESCOL
LESCOL XL
LIPITOR
lovastatin
NIASPAN
pravastatin sodium
SIMCOR
simvastatin
TRICOR
TRILIPIX
VYTORIN
WELCHOL
ZETIA
4
4
3
2
2
3
2
2
2
4
4
3
2
3
2
4
2
3
3
4
3
3
BETA-BLOCKER/DIURETIC COMBINATIONS
15
Drug
atenolol & chlorthalidone
bisoprolol & hydrochlorothiazide
metoprolol & hydrochlorothiazide
Tier
1
1
2
Notes
BETA-BLOCKERS
acebutolol hcl
atenolol
bisoprolol fumarate
BYSTOLIC
carvedilol
COREG CR
labetalol hcl
metoprolol succinate
metoprolol tartrate 100mg, 25mg, 50mg
metoprolol tartrate 1mg/ml
nadolol
pindolol
propranolol hcl 10mg, 20mg, 40mg, 80mg
propranolol hcl 120mg, 160mg, 1mg/ml,
20mg/5ml, 40mg/5ml, 60mg
propranolol hcl 80mg
2
1
2
3
2
3
2
2
1
2
2
1
1
2
2
ext rel
CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS

CADUET
CALCIUM CHANNEL BLOCKERS

amlodipine besylate
CARDIZEM CD
diltiazem hcl 120mg, 30mg, 60mg, 90mg
diltiazem hcl 120mg, 180mg, 240mg, 60mg,
90mg
diltiazem hcl 25mg/5ml
diltiazem hcl coated beads
diltiazem hcl extended release beads
felodipine
isradipine
nifedipine
NIMODIPINE
nisoldipine
verapamil hcl 120mg, 40mg, 80mg
verapamil hcl 100mg, 180mg, 2.5mg/ml,
200mg, 240mg, 300mg
verapamil hcl 120mg
2
3
1
2
2
2
2
2
2
2
5
2
1
2
2
360mg
ext rel
ext rel
ext rel
ext rel
DIGITALIS GLYCOSIDES
digoxin .125mg, .25mg
digoxin .05mg/ml, .25mg/ml
LANOXIN
1
2
3
DIRECT RENIN INHIBITORS

TEKTURNA
TEKTURNA HCT
3
3
16
Drug
Tier
Notes
DIURETICS
acetazolamide
ALDACTAZIDE
amiloride & hydrochlorothiazide
amiloride hcl
bumetanide
chlorothiazide
chlorthalidone
furosemide 10mg/ml, 20mg, 40mg, 80mg
furosemide 10mg/ml
hydrochlorothiazide
indapamide
methazolamide
metolazone
spironolactone & hydrochlorothiazide
THALITONE
torsemide 100mg, 10mg, 20mg, 5mg
TORSEMIDE 20mg/2ml
triamterene & hydrochlorothiazide
2
3
1
2
2
1
1
1
2
1
1
2
2
1
3
2
3
1
50/50
injection
injection
MISCELLANEOUS
BIDIL
hydralazine hcl
methyldopa
midodrine hcl
minoxidil
RANEXA
3
2
2
2
2
3
NITRATES
ISORDIL TITRADOSE
isosorbide dinitrate 10mg, 2.5mg, 20mg,
30mg, 5mg
isosorbide dinitrate 40mg
isosorbide mononitrate
NITRO-DUR
nitroglycerin
NITROLINGUAL PUMPSPRAY
NITROSTAT
3
1
2
2
3
2
3
3
.3mg,.8mg
PULMONARY ARTERIAL HYPERTENSION

ADCIRCA
LETAIRIS
REVATIO
TRACLEER
5
5
5
5
PA
PA
PA
LA, PA
CENTRAL NERVOUS SYSTEM

ANTIANXIETY
buspirone hcl
fluvoxamine maleate
meprobamate
2
2
2
17
Drug
Tier
Notes
ANTICONVULSANTS
BANZEL
carbamazepine
CARBATROL
CELONTIN
DILANTIN
DILANTIN INFATABS
divalproex sodium
ethosuximide
FELBATOL
gabapentin 100mg
4
2
4
3
3
3
2
2
4
2
gabapentin 300mg
gabapentin 400mg
gabapentin 600mg
gabapentin 800mg
GABITRIL
KEPPRA
lamotrigine
levetiracetam
LYRICA 100mg, 150mg, 200mg, 225mg,
25mg, 50mg, 75mg
LYRICA 300mg
NEURONTIN
4
3
2
2
3
oxcarbazepine
PEGANONE
phenytoin
phenytoin sodium
phenytoin sodium extended
primidone
SABRIL
TEGRETOL-XR
topiramate
valproate sodium
valproic acid
VIMPAT
zonisamide
2
3
2
2
2
2
5
3
2
2
2
3
2
3
3
QL (1080 caps / 25 days);

ext rel
ext rel
ext rel
QL (180 tabs / 25 days);
ext rel
QL (120 tabs / 25 days);
ext rel
injection
QL (120 caps / 25 days)

QL (5 bottles / 25 days);
solution
ANTIDEMENTIA
ARICEPT
ARICEPT ODT
EXELON 1.5mg, 2mg/ml, 3mg, 4.5mg, 6mg
EXELON 4.6mg/24hr, 9.5mg/24hr
3
3
3
3
patch
18
Drug
galantamine hydrobromide
NAMENDA
NAMENDA TITRATION PAK
Tier
2
3
3
Notes
ANTIDEPRESSANTS
amitriptyline hcl
AMOXAPINE
bupropion hcl
citalopram hydrobromide 10mg, 20mg, 40mg
citalopram hydrobromide 10mg/5ml
clomipramine hcl
CYMBALTA
desipramine hcl
doxepin hcl
EFFEXOR XR
EMSAM
fluoxetine hcl
imipramine hcl
LEXAPRO
maprotiline hcl
MARPLAN
mirtazapine
NARDIL
nefazodone hcl
nortriptyline hcl 10mg, 25mg, 50mg, 75mg
nortriptyline hcl 10mg/5ml
paroxetine hcl
PRISTIQ
protriptyline hcl
sertraline hcl
SURMONTIL
tranylcypromine sulfate
trazodone hcl 100mg, 150mg, 50mg
trazodone hcl 300mg
venlafaxine hcl
1
3
2
1
2
2
3
2
1
3
3
2
2
3
2
3
2
3
2
1
2
2
3
2
2
3
2
1
2
2
ANTIPARKINSONIAN AGENTS
amantadine hcl
APOKYN
AZILECT
benztropine mesylate .5mg, 1mg, 2mg
benztropine mesylate 1mg/ml
bromocriptine mesylate
carbidopa-levodopa
COMTAN
pramipexole dihydrochloride
REQUIP XL
ropinirole hydrochloride
2
5
3
1
2
2
2
3
2
4
2
19
Drug
selegiline hcl
STALEVO 100
STALEVO 125
STALEVO 150
STALEVO 200
STALEVO 50
STALEVO 75
trihexyphenidyl hcl
Tier
2
3
3
3
3
3
3
2
Notes
ANTIPSYCHOTICS
ABILIFY
ABILIFY DISCMELT
chlorpromazine hcl 100mg, 10mg, 200mg,
25mg, 50mg
CHLORPROMAZINE HCL 25mg/ml
clozapine 100mg, 25mg, 50mg
CLOZAPINE 200mg
FANAPT
FANAPT TITRATION PACK
FAZACLO
fluphenazine decanoate
fluphenazine hcl
GEODON
haloperidol
haloperidol decanoate
haloperidol lactate
INVEGA
INVEGA SUSTENNA 39mg/0.25ml,
78mg/0.5ml
INVEGA SUSTENNA 117mg/0.75ml,
156mg/ml, 234mg/1.5ml
loxapine succinate
NAVANE
ORAP
perphenazine
RISPERDAL CONSTA 12.5mg, 25mg
RISPERDAL CONSTA 37.5mg, 50mg
risperidone
SAPHRIS
SEROQUEL
SEROQUEL XR
thioridazine hcl
thiothixene
trifluoperazine hcl
ZYPREXA
ZYPREXA ZYDIS
4
4
2
3
2
2
4
4
4
2
2
3
2
2
2
4
4
5
2
3
3
2
3
5
2
4
3
3
2
2
2
3
3
ATTENTION DEFICIT HYPERACTIVITY DISORDER

amphetamine-dextroamphetamine
PA
20
Drug
Tier
CONCERTA
4
dexmethylphenidate hcl
2
dextroamphetamine sulfate 10mg, 15mg, 5mg 2
dextroamphetamine sulfate 10mg, 5mg
2
METADATE CD
4
METHYLIN
4
methylphenidate hcl 10mg, 20mg, 5mg
2
methylphenidate hcl 10mg, 20mg
2
RITALIN LA
4
STRATTERA
3
Notes
PA
PA
ext rel
PA
PA
PA
PA
ext rel
PA
PA
HYPNOTICS
LUNESTA
zaleplon
zolpidem tartrate
4
2
2
QL (180 tabs / year)

QL (180 caps / year)
QL (180 tabs / year)
MIGRAINE
dihydroergotamine mesylate
ergotamine w/ caffeine
FROVA
MAXALT
MAXALT-MLT
MIGERGOT
RELPAX
sumatriptan succinate 100mg, 25mg, 50mg
sumatriptan succinate 4mg/0.5ml, 6mg/0.5ml
ZOMIG 2.5mg, 5mg
ZOMIG 5mg
ZOMIG ZMT
2
2
4
3
3
3
4
2
2
4
4
4

QL
QL
QL
QL
QL
QL
(12 tabs / 25 days)

(9 tabs / 25 days)
(20 vials / 25 days)
(12 tabs / 25 days)
(2 bottles / 25 days)
(12 ea / 25 days)
MISCELLANEOUS
GUANIDINE HCL
lithium carbonate
LITHIUM CITRATE
MESTINON
MESTINON TIMESPAN
pyridostigmine bromide
REGONOL
RILUTEK
SAVELLA
SAVELLA TITRATION PACK
XENAZINE
3
2
3
3
3
2
3
5
3
3
5
PA
5
5
5
5
5
5
PA
PA
PA
PA
PA
PA
MULTIPLE SCLEROSIS AGENTS

AMPYRA
AVONEX
BETASERON
COPAXONE
EXTAVIA
REBIF
21
Drug
REBIF TITRATION PACK
Tier
5
PA
Notes
MUSCULOSKELETAL THERAPY AGENTS

baclofen
carisoprodol
chlorzoxazone
cyclobenzaprine hcl
dantrolene sodium
metaxalone
methocarbamol
orphenadrine citrate
ORPHENADRINE COMPOUND DS
orphenadrine w/ aspirin & caff
ROBAXIN
tizanidine hcl
2
1
1
2
2
2
1
2
3
2
3
2
injection
NARCOLEPSY/CATAPLEXY
PROVIGIL
XYREM
3
5
PA
LA, PA
PSYCHOTHERAPEUTIC-MISCELLANEOUS
ANTABUSE
buprenorphine hcl
bupropion hcl (smoking deterrent)
CAMPRAL
CHANTIX
naloxone hcl
naltrexone hcl
NICOTROL INHALER
NICOTROL NS
perphenazine-amitriptyline
SUBOXONE
3
2
2
3
4
2
2
4
4
2
3
PA
PA
PA
PA
PA
PA
ENDOCRINE AND METABOLIC

ANDROGENS
ANDRODERM
ANDROGEL
oxandrolone 2.5mg
OXANDROLONE 10mg
TESTIM
testosterone cypionate
testosterone enanthate
3
3
2
5
4
2
2
PA
PA
PA
PA
PA
ANTIDIABETICS
acarbose
ACTOPLUS MET
ACTOS
ALCOHOL PREPS
APIDRA
APIDRA SOLOSTAR
AVANDAMET
2
3
3
3
3
3
3
22
Drug
AVANDARYL
AVANDIA
BYETTA
DUETACT
GAUZE PADS AND DRESSINGS - PADS 2 X 2
glimepiride
glipizide 10mg, 5mg
glipizide 10mg, 2.5mg, 5mg
glipizide-metformin hcl
glyburide
glyburide micronized
glyburide-metformin
HUMALOG
HUMALOG MIX 50/50
HUMALOG MIX 50/50 PEN
HUMALOG MIX 75/25
HUMALOG MIX 75/25 PEN
HUMALOG PEN
HUMULIN 70/30
HUMULIN 70/30 PEN
HUMULIN N
HUMULIN N U-100 PEN
HUMULIN R
HUMULIN R U-500 (CONCENTR
INSULIN PEN NEEDLE
INSULIN SYRINGE (DISP) U-100 0.3 ML
INSULIN SYRINGE (DISP) U-100 1 ML
INSULIN SYRINGE (DISP) U-100 1/2 ML
JANUMET
JANUVIA
LANTUS
LANTUS SOLOSTAR
LEVEMIR
LEVEMIR FLEXPEN
metformin hcl
nateglinide
NEEDLES, INSULIN DISP., SAFETY
NOVOLIN 70/30
NOVOLIN 70/30 INNOLET
NOVOLIN N
NOVOLIN N INNOLET
NOVOLIN R
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70/30
NOVOLOG MIX 70/30 PREFILL
ONGLYZA
Tier
3
3
3
PA
3
3
2
1
2
ext rel
2
2
1
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
4
3
3
2
2
3
3
3
3
3
3
3
3
3
3
3
Notes
23
Drug
PRANDIN
RELION R
SYMLIN
SYMLINPEN 120
SYMLINPEN 60
Tier
3
3
3
PA
3
PA
3
PA
Notes
BISPHOSPHONATES
ACTONEL
alendronate sodium
BONIVA
ZOMETA
4
2
3
5
CALCITONINS
calcitonin (salmon)
MIACALCIN
2
3
injection
CALCIUM RECEPTOR ANTAGONISTS

SENSIPAR 30mg
SENSIPAR 60mg, 90mg
3
5
CHELATING AGENTS
EXJADE
sodium polystyrene sulfonate
SYPRINE
5
2
3
PA
ENDOMETRIOSIS
danazol
SYNAREL
2
3
ENZYME REPLACEMENTS
ADAGEN
ALDURAZYME
BUPHENYL
CEREZYME
CYSTADANE
CYSTAGON
ELAPRASE
FABRAZYME
KUVAN
levocarnitine (metabolic modifiers)
MYOZYME
NAGLAZYME
ORFADIN
SUCRAID
VPRIV
ZAVESCA
5
5
5
5
3
3
5
5
5
2
5
5
5
5
5
5
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
ESTROGEN/PROGESTINS
CLIMARA PRO
COMBIPATCH
FEMHRT 1/5
FEMHRT LOW DOSE
PREFEST
3
3
4
4
4
24
Drug
PREMPHASE
PREMPRO
Tier
3
3
Notes
ESTROGENS
ALORA
CENESTIN
ESTRACE
ESTRADERM
estradiol .5mg, 1mg, 2mg
estradiol .025mg/24hr, .05mg/24hr,
.06mg/24hr, .075mg/24hr, .1mg/24hr,
37.5mcg/24hr
ESTRING
estropipate
FEMRING
GYNODIOL
PREMARIN
PREMARIN W/APPLICATOR
VAGIFEM
VIVELLE-DOT
3
4
4
3
1
2
cream
4
1
4
3
3
3
3
3
GLUCOCORTICOIDS
cortisone acetate
dexamethasone .5mg, .75mg, 1.5mg, 1mg,
2mg, 4mg, 6mg
dexamethasone .5mg/5ml
DEXAMETHASONE INTENSOL
dexamethasone sodium phosphate
fludrocortisone acetate
hydrocortisone
hydrocortisone sod succinate
methylprednisolone 4mg
methylprednisolone 16mg, 32mg, 8mg
methylprednisolone acetate
methylprednisolone sod succ
prednisolone
prednisolone sodium phosphate
prednisone 10mg, 1mg, 2.5mg, 20mg, 50mg,
5mg
prednisone 5mg/5ml
PREDNISONE INTENSOL
SOLU-CORTEF
2
1
2
3
2
2
2
2
1
2
2
2
2
2
1
2
3
3
GLUCOSE ELEVATING AGENTS

GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
PROGLYCEM
3
3
3
HUMAN GROWTH HORMONES

INCRELEX
NORDITROPIN CARTRIDGE
5
5
PA
PA
25
Drug
NORDITROPIN NORDIFLEX PEN
SAIZEN
SAIZEN CLICK.EASY
TEV-TROPIN
Tier
5
5
5
5
Notes
PA
PA
PA
PA
2
2
2
5
PA
PA
PA
5
5
5
PA
PA
PA
PA
MISCELLANEOUS
cabergoline
chorionic gonadotropin
octreotide acetate 50mcg/ml
OCTREOTIDE ACETATE 1000mcg/ml,
100mcg/ml, 200mcg/ml, 500mcg/ml
SANDOSTATIN LAR DEPOT
SOMATULINE DEPOT
SOMAVERT
PARATHYROID HORMONES
FORTEO
PHOSPHATE BINDER AGENTS

calcium acetate (phosphate binder)
FOSRENOL
PHOSLO
RENAGEL
RENVELA
2
3
3
3
3
PROGESTINS
medroxyprogesterone acetate
norethindrone acetate
PROMETRIUM
1
2
4
SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA
THYROID AGENTS
levothyroxine sodium
liothyronine sodium
methimazole
propylthiouracil
SYNTHROID
1
2
2
2
3
VASOPRESSINS
desmopressin acetate
desmopressin acetate refrigerated
desmopressin acetate spray refrigerated
2
2
2
GASTROINTESTINAL
ANTIDIARRHEALS
diphenoxylate w/ atropine
diphenoxylate w/ atropine
loperamide hcl
1
2
1
tablet
4
5
QL (60 caps/25 days), PA

QL (60 caps / 25 days),
PA
ANTIEMETICS
DRONABINOL 2.5mg
DRONABINOL 10mg, 5mg
26
Drug
EMEND 80mg
EMEND 125mg
EMEND 40mg
granisetron hcl
meclizine hcl
metoclopramide hcl 10mg, 5mg, 5mg/5ml
metoclopramide hcl 5mg/ml
ondansetron
ondansetron hcl
prochlorperazine
prochlorperazine edisylate
prochlorperazine maleate
promethazine hcl 6.25mg/5ml
promethazine hcl 12.5mg, 25mg, 25mg/ml,
50mg, 50mg/ml
SANCUSO
TRANSDERM-SCOP
trimethobenzamide hcl
Tier
Notes
3
B/D, QL (4 caps / 25
days)
3
B/D, QL (2 caps / 25
days)
3
2
B/D
2
1
2
injection
2
B/D
2
B/D
2
2
1
1
2
3
3
2
QL (2 patch / 15 days)
ANTISPASMODICS
dicyclomine hcl 10mg, 20mg
dicyclomine hcl 10mg/5ml, 10mg/ml
glycopyrrolate
1
2
2
H2-RECEPTOR ANTAGONISTS
cimetidine
cimetidine hcl
famotidine
famotidine in nacl
PEPCID
ranitidine hcl
1
2
2
2
3
2
suspension
INFLAMMATORY BOWEL DISEASE

APRISO
ASACOL
CANASA
CIMZIA
DIPENTUM
ENTOCORT EC
hydrocortisone (intrarectal)
LIALDA
mesalamine
PENTASA
sulfasalazine
3
4
3
5
4
4
2
3
2
3
2
PA
LAXATIVES
HALFLYTELY BOWEL PREP
KRISTALOSE
3
4
27
Drug
lactulose
lactulose (encephalopathy)
peg 3350-kcl-sod bicarb-sod chloride-sod
sulfate
peg 3350-potassium chloride-sod bicarbonatesod chloride
polyethylene glycol 3350
RELISTOR
VISICOL
Tier
2
2
2
Notes
2
2
3
4
PA
MISCELLANEOUS
AMITIZA
CARAFATE
GASTROCROM
LOTRONEX
misoprostol
sucralfate
ursodiol
3
3
3
3
2
2
2
suspension
PANCREATIC ENZYMES
CREON
ZENPEP
3
3
PROTON PUMP INHIBITOR/ANTI-INFECTIVE COMBINATIONS

PREVPAC
PROTON PUMP INHIBITORS

DEXILANT
LANSOPRAZOLE
NEXIUM
NEXIUM I.V.
omeprazole
PANTOPRAZOLE SODIUM
ZEGERID
3
4
3
3
2
4
4
QL (90 days per year)

GENITOURINARY
BENIGN PROSTATIC HYPERPLASIA
AVODART
finasteride
tamsulosin hcl
UROXATRAL
3
2
2
3
MISCELLANEOUS
bethanechol chloride
ELMIRON
potassium citrate (alkalinizer)
THIOLA
2
4
2
3
URINARY ANTISPASMODICS
DETROL
DETROL LA
ENABLEX
GELNIQUE
4
3
3
3
28
Drug
oxybutynin chloride 5mg
oxybutynin chloride 10mg, 15mg, 5mg
oxybutynin chloride 5mg/5ml
OXYTROL
SANCTURA XR
TOVIAZ
VESICARE
Tier
1
2
ext rel
2
4
4
4
3
Notes
VAGINAL ANTI-INFECTIVES
CLEOCIN 100mg
clindamycin phosphate vaginal
metronidazole vaginal
terconazole vaginal
3
2
2
2
suppository
HEMATOLOGIC
ANTICOAGULANTS
ARIXTRA 2.5mg/0.5ml
ARIXTRA 10mg/0.8ml, 5mg/0.4ml,
7.5mg/0.6ml
COUMADIN
FRAGMIN 2500unit/0.2ml, 5000unit/0.2ml
FRAGMIN 10000unit/ml, 25000unit/ml,
7500unit/0.3ml
heparin (porcine) in sodium chloride
heparin sod (porcine) in d5w
HEPARIN SODIUM
heparin sodium (porcine)
HEPARIN SODIUM/NACL 0.45%
LOVENOX
warfarin sodium
3
5
3
3
5
2
2
3
2
3
3
1
HEMATOPOIETIC GROWTH FACTORS

LEUKINE
MOZOBIL
NEUPOGEN
PROCRIT 10000unit/ml, 2000unit/ml,
3000unit/ml, 4000unit/ml
PROCRIT 20000unit/ml, 40000unit/ml
5
5
5
3
PA
PA
PA
PA
PA
2
2
3
1
5
PA
MISCELLANEOUS
anagrelide hcl
cilostazol
CYKLOKAPRON
pentoxifylline
PROMACTA
PA
PLATELET AGGREGATION INHIBITORS

AGGRENOX
dipyridamole
EFFIENT
PLAVIX
ticlopidine hcl
3
2
3
3
2
29
Drug
Tier
Notes
IMMUNOLOGIC AGENTS
DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS)
ACTEMRA
HUMIRA
HUMIRA PEN-CROHNS DISEASE
hydroxychloroquine sulfate
leflunomide
methotrexate sodium 2.5mg
REMICADE
RHEUMATREX
5
5
5
2
2
2
5
3
PA
PA
PA
3
5
5
B/D
PA
PA
5
5
5
5
3
5
5
5
5
5
PA
PA
PA
B/D
B/D
PA
PA
PA
LA, PA
PA
3
2
2
3
2
2
2
3
3
3
5
3
3
2
5
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
PA
IMMUNOGLOBULINS
GAMASTAN S/D
GAMMAGARD LIQUID
GAMUNEX
IMMUNOMODULATORS
ACTIMMUNE
ARCALYST
INFERGEN
INTRON-A
INTRON-A W/DILUENT
PEG-INTRON
PEG-INTRON REDIPEN
PEGASYS
REVLIMID
THALOMID
IMMUNOSUPPRESSANTS
AZASAN
azathioprine
azathioprine sodium
CELLCEPT
cyclosporine
cyclosporine modified (for microemulsion)
mycophenolate mofetil
MYFORTIC
NEORAL
PROGRAF .5mg, 1mg
PROGRAF 5mg
RAPAMUNE
SANDIMMUNE
tacrolimus .5mg, 1mg
TACROLIMUS 5mg
VACCINES
ACTHIB
ADACEL
ATTENUVAX
BOOSTRIX
3
3
3
3
30
Drug
CERVARIX
COMVAX
DAPTACEL
DECAVAC
DIPHTHERIA/TETANUS TOXOID
ENGERIX-B
GARDASIL
HAVRIX
IMOVAX RABIES (H.D.C.V.)
INFANRIX
IPOL INACTIVATED IPV
IXIARO
JE-VAX
M-M-R II W/DILUENT 10 DOS
MENACTRA
MENOMUNE-A/C/Y/W-135
MERUVAX II W/DILUENT 10 D
PEDIARIX
PEDVAX HIB
PROQUAD
RABAVERT
RECOMBIVAX HB
ROTATEQ
TETANUS TOXOID ADSORBED
TETANUS/DIPHTHERIA TOXOID
TRIHIBIT
TRIPEDIA
TWINRIX
TYPHIM VI
VAQTA
VARIVAX
VIVOTIF BERNA
YF-VAX
ZOSTAVAX
Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Notes
B/D
B/D
B/D
B/D
B/D
B/D
NUTRITIONAL/SUPPLEMENTS
ELECTROLYTES
KLOR-CON M15
parenteral electrolytes
potassium chloride 10meq, 2meq/ml, 8meq
potassium chloride microencapsulated crystals
cr
sodium chloride 2.5meq/ml
sodium fluoride
3
2
2
2
B/D
2
2
IV NUTRITION
amino acid electrolyte infusion
amino acid infusion
AMINOSYN
2
2
3
B/D
B/D
B/D
31
Drug
AMINOSYN 7%/ELECTROLYTES
AMINOSYN II
AMINOSYN II 3.5%/DEXTROSE
AMINOSYN II 3.5/DEXTROSE
AMINOSYN II 4.25/DEXTROSE
AMINOSYN II 5/DEXTROSE 25
AMINOSYN II M 3.5%/DEXTRO
AMINOSYN M
AMINOSYN-HBC
AMINOSYN-PF
AMINOSYN-PF 7%
CLINIMIX 2.75%/DEXTROSE 5
CLINIMIX 5%/DEXTROSE 15%
CLINIMIX E 2.75%/DEXTROSE
CLINIMIX E 4.25%/DEXTROSE
CLINIMIX E 5%/DEXTROSE 15
fat emulsion
FREAMINE HBC 6.9%
FREAMINE III 3%
HEPATASOL
LIPOSYN II
LIPOSYN III
NEPHRAMINE
PREMASOL
PROCALAMINE
PROSOL
RENAMIN
TRAVASOL
TROPHAMINE
Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
2
3
3
3
3
3
3
3
3
3
3
3
3
Notes
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
IV REPLACEMENT SOLUTIONS
alcohol in d5w
dextrose
DEXTROSE 5%
DEXTROSE 5%/POTASSIUM CHL
dextrose w/ sodium chloride
electrolyte-m in dextrose
electrolyte-r
electrolyte-r in dextrose
IONOSOL-B/DEXTROSE 5%
2
2
3
3
2
2
2
2
3
32
Drug
IONOSOL-MB/DEXTROSE 5%
IONOSOL-T/DEXTROSE 5%
ISOLYTE-H/DEXTROSE 5%
ISOLYTE-P/DEXTROSE 5%
ISOLYTE-S
ISOLYTE-S/DEXTROSE 5%
KCL 0.15%/D10W/NACL 0.2%
KCL 0.15%/D5W/LR
KCL 0.15%/D5W/NACL 0.225%
KCL 0.3%/D5W/NACL 0.9%
lactated ringer's
MAGNESIUM SULFATE IN D5W
NORMOSOL-R
PLASMA-LYTE 56
PLASMA-LYTE A
PLASMA-LYTE-148
PLASMA-LYTE-148/D5W
PLASMA-LYTE-56/D5W
potassium chloride .4meq/ml, 10meq/100ml,
10meq/50ml, 30meq/100ml
POTASSIUM CHLORIDE 0.15%
POTASSIUM CHLORIDE 0.3%/
potassium chloride in d5w lactated ringers
potassium chloride in dextrose
potassium chloride in dextrose & sodium
chloride
potassium chloride in nacl
ringer's
sodium chloride .45%, .9%, 3%, 5%
Tier
3
3
3
3
3
3
3
3
3
3
2
3
3
3
3
3
3
3
2
Notes
3
3
2
2
2
2
2
2
VITAMINS
calcitriol .25mcg, .5mcg
calcitriol 1mcg/ml
CALCITRIOL 2mcg/ml
HECTOROL
prenatal without a vit w/ iron carbonyl-folic
acid
ZEMPLAR
2
2
3
4
2
capsule
OPHTHALMIC
ANTI-INFECTIVE/ANTI-INFLAMMATORY
bacitracin-poly-neomycin-hc
BLEPHAMIDE S.O.P.
neomycin-polymy-dexameth
neomycin-polymyxin-hc (ophth)
sulfacetamide sod-prednisolone
TOBRADEX
tobramycin-dexamethasone
1
3
1
2
2
4
2
ANTI-INFECTIVES
33
Drug
AZASITE
bacitracin (ophthalmic)
bacitracin-polymyxin b (ophth)
CILOXAN
ciprofloxacin hcl (ophth)
erythromycin (ophth)
gentamicin sulfate (ophth) .3%
gentamicin sulfate (ophth) .3%
NATACYN
neomycin-bacitracin zn-polymyxin
neomycin-polymy-gramicid
ofloxacin (ophth)
polymyxin b-trimethoprim
QUIXIN
sulfacetamide sodium (ophth)
tobramycin sulfate (ophth)
TOBREX
trifluridine
VIGAMOX
ZYMAR
Tier
Notes
3
2
2
3
ointment
2
1
1
2
ointment
3
1
2
2
1
4
1
1
3
ointment
2
3
3
ANTI-INFLAMMATORIES
dexamethasone sodium phosphate (ophth)
diclofenac sodium (ophth)
fluorometholone (ophth)
flurbiprofen sodium
FML
ketorolac tromethamine (ophth)
LOTEMAX
PRED MILD
prednisolone acetate (ophth)
PREDNISOLONE SODIUM PHOSP
XIBROM
2
2
1
1
3
2
4
4
1
3
4
ANTIALLERGICS
ALOCRIL
ALOMIDE
ALREX
azelastine hcl (ophth)
cromolyn sodium (ophth)
PATADAY
PATANOL
4
4
3
2
2
3
3
ANTIGLAUCOMA
AZOPT
BETIMOL
BETOPTIC-S
brimonidine tartrate
carteolol hcl (ophth)
3
4
3
2
2
34
Drug
COMBIGAN
dorzolamide hcl
dorzolamide-timolol
levobunolol hcl
LUMIGAN
metipranolol
PILOPINE HS
timolol maleate (ophth) .25%, .5%
timolol maleate (ophth) .25%, .5%
TRAVATAN Z
XALATAN
Tier
3
2
2
1
3
2
3
1
2
3
4
Notes
QL (2.5ml / 25 days)
gel
QL (2.5ml / 25 days)
QL (1 bottle / 25 days)
MISCELLANEOUS
LACRISERT
naphazoline hcl
proparacaine hcl
RESTASIS
3
1
2
3
RESPIRATORY
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS
COMBIVENT
ipratropium-albuterol
3
2
QL (2 inhalers / 25 days)
B/D, QL (180 vials / 25
days)
ATROVENT HFA
ipratropium bromide
3
2
B/D, QL (126 bags / 25
days)
ipratropium bromide (nasal)

SPIRIVA HANDIHALER
2
3
ANTICHOLINERGICS
ANTIHISTAMINES, LOW/NONSEDATING
ASTEPRO
azelastine hcl
cetirizine hcl
fexofenadine hcl
XYZAL
2
2
2
3
QL (2 spray-bottles / 25
days)
QL (2 bottles / 25 days)
ANTIHISTAMINES, SEDATING
clemastine fumarate
cyproheptadine hcl
diphenhydramine hcl 12.5mg/5ml, 50mg
diphenhydramine hcl 50mg/ml
hydroxyzine hcl
hydroxyzine pamoate
2
2
1
2
2
1
BETA AGONISTS
albuterol sulfate 2mg, 2mg/5ml, 4mg
albuterol sulfate .083%, .63mg/3ml,
1.25mg/3ml
albuterol sulfate .5%
1
2
2
B/D, QL (100 bags / 25

days)
B/D, QL (3 bottles / 25
days)
35
Drug
albuterol sulfate 4mg, 8mg
FORADIL AEROLIZER
levalbuterol hcl
PROAIR HFA
PROVENTIL HFA
SEREVENT DISKUS
terbutaline sulfate
XOPENEX
XOPENEX HFA
Tier
Notes
2
4
2
B/D, QL (90 bags / 25
days)
3
4
3
QL (1 inhaler / 25 days)
2
4
B/D, QL (96 bags / 25
days)
4
LEUKOTRIENE RECEPTOR ANTAGONISTS

ACCOLATE
SINGULAIR
4
3
MAST CELL STABILIZERS

cromolyn sodium
B/D, QL (120 bags / 25

days)
2
5
2
3
3
5
5
3
3
5
B/D
PA
2
2
3
4
4
QL
QL
QL
QL
QL
(2
(1
(1
(2
(2
bottles / 25 days)
bottle / 25 days)
inhaler / 25 days)
inhalers / 25 days)
inhalers / 25 days)
3
3
3
3
3
3
4
QL
QL
QL
QL
QL
QL
QL
(2
(2
(2
(2
(2
(2
(3
inhalers
inhalers
inhalers
inhalers
inhalers
inhalers
inhalers
MISCELLANEOUS
acetylcysteine
ARALAST NP
epinephrine hcl
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
PULMOZYME
TOBI
TYZINE
TYZINE PEDIATRIC NASAL DR
XOLAIR
B/D
B/D
PA
NASAL STEROIDS
flunisolide (nasal)
fluticasone propionate (nasal)
NASACORT AQ
NASONEX
RHINOCORT AQUA
STEROID INHALANTS
ASMANEX 120 METERED DOSES
FLOVENT DISKUS
FLOVENT HFA
QVAR
/
/
/
/
/
/
/
25
25
25
25
25
25
25
days)
days)
days)
days)
days)
days)
days)
STEROID/BETA-AGONIST COMBINATIONS
ADVAIR DISKUS
ADVAIR HFA
PULMICORT FLEXHALER 180mcg/act
3
3
4
QL (1 kit / 25 days)
36
Drug
PULMICORT FLEXHALER 90mcg/act
SYMBICORT
Tier
Notes
4
3
XANTHINES
aminophylline 100mg, 200mg
aminophylline 25mg/ml
ELIXOPHYLLIN
THEO-24
theophylline
1
2
3
3
2
TOPICAL
DERMATOLOGY, ACNE
AZELEX
benzoyl peroxide-erythromycin
clindamycin phosphate (topical)
clindamycin phosphate-benzoyl peroxide
erythromycin (acne aid)
isotretinoin
RETIN-A MICRO
sulfacetamide sodium (acne)
tretinoin .01%, .025%, .05%, .1%
4
2
2
2
2
2
4
2
2
PA
PA
DERMATOLOGY, ACTINIC KERATOSIS

CARAC
FLUOROPLEX
fluorouracil (topical)
SOLARAZE
3
4
2
3
DERMATOLOGY, ANTIBIOTICS
ALTABAX
BACTROBAN
gentamicin sulfate (topical)
mupirocin
silver sulfadiazine
3
3
1
2
1
cream
DERMATOLOGY, ANTIFUNGALS
ciclopirox
ciclopirox olamine
clotrimazole (topical)
econazole nitrate
ketoconazole (topical) 2%
MENTAX
nystatin (topical) 100000unit/gm
nystatin (topical) 100000unit/gm
OXISTAT
2
2
2
2
2
4
1
2
4
cream,ointment
DERMATOLOGY, ANTIPRURITIC
hydrocortisone (rectal)
ZONALON
1
3
DERMATOLOGY, ANTIPSORIATICS
calcipotriene
DOVONEX
2
3
cream
37
Drug
OXSORALEN ULTRA
SORIATANE
STELARA
Tier
5
PA
4
5
PA
Notes
DERMATOLOGY, ANTISEBORRHEICS
ketoconazole (topical) 2%
selenium sulfide
2
2
DERMATOLOGY, ANTIVIRALS
DENAVIR
ZOVIRAX
3
3
cream,ointment
DERMATOLOGY, CORTICOSTEROIDS
alclometasone dipropionate
2
betamethasone dipropionate (topical)
1
betamethasone dipropionate augmented
2
betamethasone valerate
1
clobetasol propionate
2
clobetasol propionate emollient base
2
CORDRAN
4
CORDRAN TAPE
4
DERMA-SMOOTHE/FS BODY OIL
3
desonide
2
DESOWEN OINTMENT/CETAPHIL
3
desoximetasone
2
diflorasone diacetate
2
fluocinolone acetonide
2
fluocinonide
2
fluocinonide emulsified base
2
fluticasone propionate
2
halobetasol propionate
2
hydrocortisone (topical)
1
hydrocortisone butyrate
2
hydrocortisone valerate
2
KENALOG
3
LOCOID LIPOCREAM
4
LUXIQ
4
mometasone furoate
2
triamcinolone acetonide (topical) .025%, .1%, 1
.5%
triamcinolone acetonide (topical) .025%, .1% 2
cream,ointment
DERMATOLOGY, IMMUNOMODULATORS
ELIDEL
PROTOPIC
3
3
PA
PA
2
2
2
3
PA
DERMATOLOGY, LOCAL ANESTHETICS

lidocaine
lidocaine hcl
lidocaine-prilocaine
LIDODERM
38
Drug
Tier
Notes
DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE

CONDYLOX
imiquimod
lactic acid (ammonium lactate)
PANRETIN
podofilox
TARGRETIN 1%
4
2
2
5
2
5
DERMATOLOGY, ROSACEA
FINACEA
METROGEL
metronidazole (topical)
ORACEA
4
3
2
3
DERMATOLOGY, SCABICIDES AND PEDICULIDES

EURAX
malathion
permethrin
3
2
1
DERMATOLOGY, WOUND CARE AGENTS

REGRANEX
SANTYL
sodium chloride (gu irrigant)
5
3
2
PA
MOUTH/THROAT/DENTAL AGENTS
chlorhexidine gluconate (mouth-throat)
EVOXAC
lidocaine hcl (mouth-throat)
nystatin (mouth-throat)
pilocarpine hcl (oral)
triamcinolone acetonide (mouth)
1
3
1
2
2
2
OTIC
acetic acid (otic)
acetic acid-aluminum acetate
CIPRO HC
CIPRODEX
DERMOTIC
hydrocortisone w/acetic acid
neomycin-polymyxin-hc (otic)
ofloxacin (otic)
2
2
4
4
3
2
2
2
39
Index
A
ABILIFY ..................................20
ABILIFY DISCMELT ...................20
acarbose .................................22
ACCOLATE ..............................36
acebutolol hcl ..........................16
acetaminophen w/ codeine ......... 6
acetazolamide .........................17
acetic acid (otic) ......................39
acetic acid-aluminum acetate.....39
acetylcysteine..........................36
ACTEMRA ................................30
ACTHIB...................................30
ACTIMMUNE ............................30
ACTONEL ................................24
ACTOPLUS MET........................22
ACTOS....................................22
acyclovir .................................10
acyclovir sodium ......................10
ADACEL ..................................30
ADAGEN .................................24
ADCIRCA ................................17
ADVAIR DISKUS ......................36
ADVAIR HFA ............................36
ADVICOR ................................15
AFINITOR................................13
AGGRENOX .............................29
ALBENZA ................................10
albuterol sulfate ................. 35, 36
alclometasone dipropionate .......38
alcohol in d5w .........................32
ALCOHOL PREPS ......................22
ALDACTAZIDE .........................17
ALDURAZYME ..........................24
alendronate sodium ..................24
ALIMTA...................................12
ALINIA....................................10
allopurinol ................................ 6
allopurinol sodium ..................... 6
ALOCRIL .................................34
ALOMIDE ................................34
ALORA ....................................25
ALREX ....................................34
ALTABAX.................................37
ALTOPREV...............................15
amantadine hcl ........................19
amifostine crystalline................ 13
amikacin sulfate.........................7
amiloride & hydrochlorothiazide . 17
amiloride hcl ........................... 17
amino acid electrolyte infusion ... 31
amino acid infusion .................. 31
aminophylline .......................... 37
AMINOSYN .............................. 31
AMINOSYN 7%/ELECTROLYTES.. 32
AMINOSYN II........................... 32
AMINOSYN II 3.5%/DEXTROSE .. 32
AMINOSYN II 3.5/DEXTROSE ..... 32
AMINOSYN II 4.25/DEXTROSE ... 32
AMINOSYN II 5/DEXTROSE 25 ... 32
AMINOSYN II M 3.5%/DEXTRO .. 32
AMINOSYN M........................... 32
AMINOSYN-HBC....................... 32
AMINOSYN-PF ......................... 32
AMINOSYN-PF 7%.................... 32
amiodarone hcl ........................ 15
AMITIZA ................................. 28
amitriptyline hcl....................... 19
amlodipine besylate ................. 16
amlodipine besylate-benazepril hcl
............................................. 14
AMOXAPINE ............................ 19
amoxicillin ................................7
amoxicillin & pot clavulanate .......7
amphetamine-dextroamphetamine
............................................. 20
amphotericin b ..........................8
ampicillin ..................................7
ampicillin & sulbactam sodium .....7
ampicillin sodium .......................7
AMPYRA.................................. 21
anagrelide hcl.......................... 29
ANCOBON .................................8
ANDRODERM ........................... 22
ANDROGEL ............................. 22
ANTABUSE .............................. 22
ANTARA.................................. 15
APIDRA .................................. 22
APIDRA SOLOSTAR .................. 22
APOKYN.................................. 19
APRISO .................................. 27
APTIVUS ...................................9
ARALAST NP............................ 36
40
ARCALYST ...............................30
ARICEPT .................................18
ARICEPT ODT ..........................18
ARIMIDEX ...............................12
ARIXTRA .................................29
AROMASIN ..............................12
ASACOL ..................................27
ASMANEX 120 METERED DOSES.36
ASMANEX 14 METERED DOSES ..36
ASTEPRO ................................35
ATACAND................................15
ATACAND HCT .........................14
atenolol ..................................16
atenolol & chlorthalidone ...........16
ATRIPLA .................................. 9
ATROVENT HFA........................35
ATTENUVAX ............................30
AVANDAMET............................22
AVANDARYL ............................23
AVANDIA ................................23
AVASTIN.................................12
AVELOX ................................... 7
AVELOX ABC PACK .................... 7
AVINZA ................................... 6
AVODART................................28
AVONEX..................................21
AZASAN..................................30
AZASITE .................................34
azathioprine ............................30
azathioprine sodium .................30
azelastine hcl...........................35
azelastine hcl (ophth) ...............34
AZELEX...................................37
AZILECT .................................19
azithromycin ............................ 7
AZOPT ....................................34
B
bacitracin (ophthalmic) .............34
bacitracin-polymyxin b (ophth) ..34
bacitracin-poly-neomycin-hc ......33
baclofen..................................22
BACTROBAN ............................37
BANZEL ..................................18
BARACLUDE ............................10
benazepril & hydrochlorothiazide 14
benazepril hcl .......................... 14

BENICAR ................................ 15
BENICAR HCT .......................... 15
benzoyl peroxide-erythromycin .. 37
benztropine mesylate ............... 19
betamethasone dipropionate
(topical) ................................. 38
betamethasone dipropionate
augmented ............................. 38
betamethasone valerate............ 38
BETASERON ............................ 21
bethanechol chloride ................ 28
BETIMOL ................................ 34
BETOPTIC-S ............................ 34
bicalutamide ........................... 12
BICILLIN C-R.............................7
BICILLIN L-A .............................7
BICNU .................................... 11
BIDIL ..................................... 17
bisoprolol & hydrochlorothiazide. 16
bisoprolol fumarate .................. 16
bleomycin sulfate ..................... 12
BLEPHAMIDE S.O.P. ................. 33
BONIVA .................................. 24
BOOSTRIX .............................. 30
brimonidine tartrate ................. 34
bromocriptine mesylate ............ 19
bumetanide............................. 17
BUPHENYL .............................. 24
buprenorphine hcl .................... 22
bupropion hcl .......................... 19
bupropion hcl (smoking deterrent)
............................................. 22
buspirone hcl........................... 17
BUSULFEX .............................. 11
butalbital-acetaminophen-caffeine
w/ codeine ................................6
butalbital-aspirin-caffeine w/cod ..6
butorphanol tartrate ...................6
BYETTA .................................. 23
BYSTOLIC ............................... 16
C
cabergoline ............................. 26
CADUET.................................. 16
calcipotriene............................ 37
calcitonin (salmon)................... 24
calcitriol.................................. 33
41
CALCITRIOL ............................33
calcium acetate (phosphate binder)
.............................................26
CAMPATH ................................12
CAMPRAL ................................22
CANASA..................................27
CANCIDAS ............................... 8
CAPASTAT SULFATE .................10
captopril .................................14
captopril & hydrochlorothiazide ..14
CARAC....................................37
CARAFATE...............................28
carbamazepine ........................18
CARBATROL ............................18
carbidopa-levodopa ..................19
carboplatin ..............................13
CARDIZEM CD .........................16
carisoprodol ............................22
carteolol hcl (ophth) .................34
carvedilol ................................16
CEDAX..................................... 7
CEENU....................................11
cefaclor ................................... 7
CEFACLOR ER ........................... 7
cefadroxil ................................. 7
cefazolin sodium ....................... 7
CEFAZOLIN SODIUM.................. 7
cefdinir .................................... 7
cefepime hcl ............................. 7
cefotaxime sodium .................... 7
cefoxitin sodium........................ 7
cefpodoxime proxetil ................. 8
cefprozil................................... 8
ceftriaxone sodium .................... 8
cefuroxime axetil ...................... 8
cefuroxime sodium .................... 8
CEFUROXIME/DEXTROSE ........... 8
CELEBREX ................................ 6
CELLCEPT ...............................30
CELONTIN ...............................18
CENESTIN ...............................25
cephalexin................................ 8
CEREZYME ..............................24
CERVARIX ...............................31
cetirizine hcl ............................35
CHANTIX.................................22
chlorhexidine gluconate (mouththroat)....................................39
chloroquine phosphate................9
chlorothiazide .......................... 17
chlorpromazine hcl ................... 20
CHLORPROMAZINE HCL ............ 20
chlorthalidone ......................... 17
chlorzoxazone ......................... 22
cholestyramine light ................. 15
chorionic gonadotropin ............. 26
ciclopirox ................................ 37
ciclopirox olamine .................... 37
cilostazol ................................ 29
CILOXAN ................................ 34
cimetidine ............................... 27
cimetidine hcl .......................... 27
CIMZIA................................... 27
CIPRO ......................................8
CIPRO HC ............................... 39
CIPRODEX .............................. 39
ciprofloxacin..............................8
ciprofloxacin hcl .........................8
ciprofloxacin hcl (ophth) ........... 34
ciprofloxacin-ciprofloxacin hcl ......8
cisplatin.................................. 13
citalopram hydrobromide .......... 19
cladribine................................ 13
clarithromycin ...........................8
clemastine fumarate................. 35
CLEOCIN .......................... 10, 29
CLEOCIN PEDIATRIC GRANULE .. 10
CLIMARA PRO.......................... 24
clindamycin hcl ........................ 10
clindamycin phosphate ............. 10
clindamycin phosphate (topical) . 37
clindamycin phosphate vaginal... 29
clindamycin phosphate-benzoyl
peroxide ................................. 37
CLINIMIX 2.75%/DEXTROSE 5... 32
CLINIMIX 5%/DEXTROSE 15% .. 32
CLINIMIX E 2.75%/DEXTROSE... 32
CLINIMIX E 4.25%/DEXTROSE... 32
CLINIMIX E 5%/DEXTROSE 15... 32
42
clobetasol propionate................38
clobetasol propionate emollient
base.......................................38
clomipramine hcl......................19
clonidine hcl ............................14
clotrimazole.............................. 8
clotrimazole (topical) ................37
clozapine ................................20
CLOZAPINE .............................20
COARTEM................................. 9
colchicine w/ probenecid ............ 6
COLCRYS ................................. 6
colestipol hcl ...........................15
colistimethate sodium ...............10
COMBIGAN..............................35
COMBIPATCH...........................24
COMBIVENT ............................35
COMBIVIR ................................ 9
COMTAN .................................19
COMVAX .................................31
CONCERTA ..............................21
CONDYLOX..............................39
COPAXONE..............................21
CORDRAN ...............................38
CORDRAN TAPE .......................38
COREG CR...............................16
cortisone acetate .....................25
COSMEGEN .............................12
COUMADIN..............................29
CREON ...................................28
CRESTOR ................................15
CRIXIVAN ................................ 9
cromolyn sodium......................36
cromolyn sodium (ophth) ..........34
CUBICIN .................................11
cyclobenzaprine hcl ..................22
cyclophosphamide ....................11
cyclosporine ............................30
cyclosporine modified (for
microemulsion) ........................30
CYKLOKAPRON ........................29
CYMBALTA ..............................19
cyproheptadine hcl ...................35
CYSTADANE ............................24
CYSTAGON..............................24
cytarabine...............................12
D
dacarbazine ............................ 11
danazol .................................. 24
dantrolene sodium ................... 22
dapsone ................................. 11
DAPTACEL............................... 31
DARAPRIM ................................9
daunorubicin hcl ...................... 11
DECAVAC................................ 31
DENAVIR ................................ 38
DEPO-PROVERA ....................... 12
DERMA-SMOOTHE/FS BODY OIL. 38
DERMOTIC .............................. 39
desipramine hcl ....................... 19
desmopressin acetate ............... 26
desmopressin acetate refrigerated
............................................. 26
desmopressin acetate spray
refrigerated............................. 26
desonide................................. 38
DESOWEN OINTMENT/CETAPHIL 38
desoximetasone....................... 38
DETROL .................................. 28
DETROL LA ............................. 28
dexamethasone ....................... 25
DEXAMETHASONE INTENSOL..... 25
............................................. 25
(ophth)................................... 34
DEXILANT ............................... 28
dexmethylphenidate hcl ............ 21
dexrazoxane ........................... 13
dextroamphetamine sulfate ....... 21
dextrose ................................. 32
DEXTROSE 5% ........................ 32
DEXTROSE 5%/POTASSIUM CHL 32
dextrose w/ sodium chloride ...... 32
diclofenac potassium ..................6
diclofenac sodium ......................7
diclofenac sodium (ophth) ......... 34
dicloxacillin sodium ....................8
dicyclomine hcl ........................ 27
didanosine ................................9
diflorasone diacetate ................ 38
diflunisal...................................7
digoxin ................................... 16
dihydroergotamine mesylate...... 21
43
DILANTIN................................18
DILANTIN INFATABS.................18
DILAUDID-5 ............................. 6
diltiazem hcl ............................16
diltiazem hcl coated beads.........16
diltiazem hcl extended release
beads .....................................16
DIOVAN ..................................15
DIOVAN HCT ...........................14
DIPENTUM ..............................27
diphenhydramine hcl ................35
diphenoxylate w/ atropine .........26
DIPHTHERIA/TETANUS TOXOID..31
dipyridamole ...........................29
disopyramide phosphate ...........15
divalproex sodium ....................18
dorzolamide hcl .......................35
dorzolamide-timolol ..................35
DOVONEX ...............................37
doxazosin mesylate ..................14
doxepin hcl .............................19
DOXIL ....................................11
doxorubicin hcl ........................11
doxycycline (monohydrate) ........ 8
doxycycline hyclate ................... 8
DRONABINOL ..........................26
DROXIA ..................................13
DUETACT ................................23
E
econazole nitrate......................37
EFFEXOR XR ............................19
EFFIENT..................................29
ELAPRASE ...............................24
electrolyte-m in dextrose ..........32
electrolyte-r ............................32
electrolyte-r in dextrose ............32
ELIDEL ...................................38
ELITEK ...................................13
ELIXOPHYLLIN .........................37
ELMIRON ................................28
ELSPAR...................................13
EMCYT ....................................11
EMEND ...................................27
EMSAM ...................................19
EMTRIVA.................................. 9
ENABLEX ................................28
enalapril maleate .....................14
enalapril maleate &

hydrochlorothiazide .................. 14
ENGERIX-B ............................. 31
ENTOCORT EC ......................... 27
epinephrine hcl ........................ 36
EPIPEN 2-PAK.......................... 36
EPIPEN-JR 2-PAK ..................... 36
EPIRUBICIN HCL ...................... 11
EPIVIR .....................................9
EPIVIR HBV............................. 10
eplerenone.............................. 14
EPZICOM ..................................9
ergotamine w/ caffeine ............. 21
ERYPED 200 ..............................8
ERYTHROCIN LACTOBIONATE ......8
erythromycin (acne aid)............ 37
erythromycin (ophth) ............... 34
erythromycin base .....................8
erythromycin ethylsuccinate ........8
erythromycin stearate ................8
erythromycin-sulfisoxazole ........ 11
ESTRACE ................................ 25
ESTRADERM ............................ 25
estradiol ................................. 25
ESTRING ................................ 25
estropipate ............................. 25
ethambutol hcl ........................ 10
ethosuximide........................... 18
etodolac ...................................7
etoposide................................ 13
EURAX.................................... 39
EVISTA................................... 26
EVOXAC.................................. 39
EXELON .................................. 18
EXFORGE ................................ 14
EXFORGE HCT ......................... 14
EXJADE .................................. 24
EXTAVIA ................................. 21
F
FABRAZYME ............................ 24
famciclovir .............................. 10
famotidine .............................. 27
famotidine in nacl .................... 27
FANAPT .................................. 20
FANAPT TITRATION PACK.......... 20
FARESTON .............................. 12
FASLODEX .............................. 12
44
fat emulsion ............................32

FAZACLO ................................20
FELBATOL ...............................18
felodipine ................................16
FEMARA ..................................12
FEMHRT 1/5 ............................24
FEMHRT LOW DOSE..................24
FEMRING ................................25
fenofibrate ..............................15
fenofibrate micronized ..............15
fentanyl ................................... 6
fentanyl citrate ......................... 6
fexofenadine hcl.......................35
FINACEA .................................39
finasteride...............................28
flecainide acetate .....................15
FLOVENT DISKUS.....................36
FLOVENT HFA ..........................36
fluconazole............................8, 9
fluconazole in dextrose .............. 9
FLUDARABINE PHOSPHATE........13
fludrocortisone acetate..............25
flunisolide (nasal).....................36
fluocinolone acetonide ..............38
fluocinonide.............................38
fluocinonide emulsified base ......38
fluorometholone (ophth) ...........34
FLUOROPLEX ...........................37
fluorouracil..............................12
fluorouracil (topical) .................37
fluoxetine hcl...........................19
fluphenazine decanoate.............20
fluphenazine hcl .......................20
flurbiprofen .............................. 7
flurbiprofen sodium ..................34
flutamide ................................12
fluticasone propionate...............38
fluticasone propionate (nasal) ....36
fluvoxamine maleate ................17
FML........................................34
FORADIL AEROLIZER ................36
FORTEO ..................................26
fosinopril sodium......................14
fosinopril sodium &
hydrochlorothiazide ..................14
FOSRENOL ..............................26
FRAGMIN ................................29
FREAMINE HBC 6.9%................32
FREAMINE III 3%..................... 32

FROVA.................................... 21
FURADANTIN........................... 11
furosemide.............................. 17
FUZEON....................................9
G
gabapentin.............................. 18
GABITRIL................................ 18
galantamine hydrobromide ........ 19
GAMASTAN S/D ....................... 30
GAMMAGARD LIQUID ............... 30
GAMUNEX ............................... 30
ganciclovir .............................. 10
GANCICLOVIR ......................... 10
GARDASIL .............................. 31
GASTROCROM ......................... 28
GAUZE PADS AND DRESSINGS PADS 2 X 2 ............................. 23
GELNIQUE .............................. 28
gemfibrozil.............................. 15
GEMZAR ................................. 12
gentamicin in saline ...................8
gentamicin sulfate......................8
gentamicin sulfate (ophth) ........ 34
gentamicin sulfate (topical) ....... 37
GEODON................................. 20
GLEEVEC ................................ 13
glimepiride.............................. 23
glipizide.................................. 23
glipizide-metformin hcl ............. 23
GLUCAGEN HYPOKIT ................ 25
GLUCAGON EMERGENCY KIT ..... 25
glyburide ................................ 23
glyburide micronized ................ 23
glyburide-metformin................. 23
glycopyrrolate ......................... 27
granisetron hcl ........................ 27
griseofulvin microsize .................9
GRIS-PEG .................................9
guanfacine hcl ......................... 14
GUANIDINE HCL ...................... 21
GYNODIOL .............................. 25
H
HALFLYTELY BOWEL PREP ......... 27
halobetasol propionate.............. 38
haloperidol.............................. 20
45
haloperidol decanoate ...............20

haloperidol lactate....................20
HAVRIX ..................................31
HECTOROL ..............................33
heparin (porcine) in sodium
chloride ..................................29
heparin sod (porcine) in d5w .....29
HEPARIN SODIUM ....................29
heparin sodium (porcine) ..........29
HEPARIN SODIUM/NACL 0.45% .29
HEPATASOL.............................32
HEPSERA ................................10
HERCEPTIN .............................12
HEXALEN ................................11
HUMALOG ...............................23
HUMALOG MIX 50/50................23
HUMALOG MIX 50/50 PEN .........23
HUMALOG MIX 75/25................23
HUMALOG MIX 75/25 PEN .........23
HUMALOG PEN.........................23
HUMIRA ..................................30
HUMIRA PEN-CROHNS DISEASE .30
HUMULIN 70/30 .......................23
HUMULIN 70/30 PEN ................23
HUMULIN N .............................23
HUMULIN N U-100 PEN .............23
HUMULIN R .............................23
HUMULIN R U-500 (CONCENTR ..23
HYCAMTIN ..............................13
hydralazine hcl ........................17
hydrocodone-acetaminophen ...... 6
hydrocortisone.........................25
hydrocortisone (intrarectal) .......27
hydrocortisone (rectal)..............37
hydrocortisone (topical) ............38
hydrocortisone butyrate ............38
hydrocortisone sod succinate .....25
hydrocortisone valerate.............38
hydrocortisone w/acetic acid ......39
hydromorphone hcl ................... 6
hydroxychloroquine sulfate ........30
hydroxyurea ............................13
hydroxyzine hcl........................35
hydroxyzine pamoate ...............35
I
ibuprofen ................................. 7
idarubicin hcl........................... 11
IFEX....................................... 11
IFOSFAMIDE ........................... 11
ifosfamide & mesna.................. 13
imipramine hcl......................... 19
imiquimod............................... 39
IMOVAX RABIES (H.D.C.V.) ....... 31
INCRELEX ............................... 25
indapamide ............................. 17
INDOCIN ..................................7
indomethacin ............................7
INFANRIX ............................... 31
INFERGEN............................... 30
INSULIN PEN NEEDLE ............... 23
INSULIN SYRINGE (DISP) U-100
0.3 ML.................................... 23
INSULIN SYRINGE (DISP) U-100 1
ML ......................................... 23
INSULIN SYRINGE (DISP) U-100
1/2 ML ................................... 23
INTELENCE ...............................9
INTRON-A ............................... 30
INTRON-A W/DILUENT.............. 30
INVANZ .................................. 11
INVEGA .................................. 20
INVEGA SUSTENNA .................. 20
INVIRASE .................................9
IONOSOL-B/DEXTROSE 5% ....... 32
IONOSOL-MB/DEXTROSE 5% .... 33
IONOSOL-T/DEXTROSE 5% ....... 33
IPOL INACTIVATED IPV............. 31
ipratropium bromide................. 35
ipratropium bromide (nasal) ...... 35
ipratropium-albuterol................ 35
IRINOTECAN ........................... 13
ISENTRESS ...............................9
ISOLYTE-H/DEXTROSE 5% ........ 33
ISOLYTE-P/DEXTROSE 5% ........ 33
ISOLYTE-S .............................. 33
ISOLYTE-S/DEXTROSE 5% ........ 33
isoniazid ................................. 10
ISORDIL TITRADOSE ................ 17
isosorbide dinitrate................... 17
isosorbide mononitrate ............. 17
isotretinoin ............................. 37
isradipine................................ 16
ISTODAX ................................ 12
itraconazole ..............................9
46
IXIARO ...................................31
J
JANUMET ................................23
JANUVIA .................................23
JE-VAX ...................................31
K
KADIAN ................................... 6
KALETRA.................................. 9
KCL 0.15%/D10W/NACL 0.2% ...33
KCL 0.15%/D5W/LR .................33
KCL 0.15%/D5W/NACL 0.225% .33
KCL 0.3%/D5W/NACL 0.9%.......33
KENALOG ................................38
KEPPRA ..................................18
ketoconazole ............................ 9
ketoconazole (topical)......... 37, 38
ketoprofen ............................... 7
ketorolac tromethamine ............. 7
ketorolac tromethamine (ophth).34
KLOR-CON M15........................31
KRISTALOSE ...........................27
KUVAN ...................................24
L
labetalol hcl.............................16
LACRISERT..............................35
lactated ringer's .......................33
lactic acid (ammonium lactate) ..39
lactulose .................................28
lactulose (encephalopathy) ........28
lamotrigine..............................18
LANOXIN ................................16
LANSOPRAZOLE .......................28
LANTUS ..................................23
LANTUS SOLOSTAR ..................23
leflunomide .............................30
LESCOL ..................................15
LESCOL XL ..............................15
LETAIRIS ................................17
leucovorin calcium....................13
LEUCOVORIN CALCIUM .............13
LEUKERAN ..............................11
LEUKINE .................................29
leuprolide acetate.....................12
levalbuterol hcl ........................36
LEVAQUIN ................................ 8
LEVEMIR .................................23
LEVEMIR FLEXPEN.................... 23
levetiracetam .......................... 18
levobunolol hcl ........................ 35
levocarnitine (metabolic modifiers)
............................................. 24
levothyroxine sodium ............... 26
LEXAPRO ................................ 19
LEXIVA .....................................9
LIALDA ................................... 27
lidocaine ................................. 38
lidocaine hcl ............................ 38
lidocaine hcl (local anesth.) .........7
lidocaine hcl (mouth-throat) ...... 39
lidocaine-prilocaine .................. 38
LIDODERM .............................. 38
liothyronine sodium.................. 26
LIPITOR.................................. 15
LIPOSYN II.............................. 32
LIPOSYN III ............................ 32
lisinopril ................................. 14
lisinopril & hydrochlorothiazide... 14
lithium carbonate ..................... 21
LITHIUM CITRATE .................... 21
LOCOID LIPOCREAM................. 38
loperamide hcl......................... 26
losartan potassium ................... 15
losartan potassium &
hydrochlorothiazide .................. 14
LOTEMAX................................ 34
LOTREL .................................. 14
LOTRONEX .............................. 28
lovastatin................................ 15
LOVENOX................................ 29
loxapine succinate.................... 20
LUMIGAN ................................ 35
LUNESTA ................................ 21
LUPRON DEPOT ....................... 12
LUPRON DEPOT-PED................. 12
LUXIQ .................................... 38
LYRICA ................................... 18
LYSODREN .............................. 13
M
MACRODANTIN ........................ 11
MAGNESIUM SULFATE IN D5W... 33
MALARONE................................9
malathion ............................... 39
maprotiline hcl......................... 19
47
MARPLAN ................................19
MATULANE ..............................13
MAXALT ..................................21
MAXALT-MLT ...........................21
mebendazole ...........................11
meclizine hcl ...........................27
medroxyprogesterone acetate ....26
mefloquine hcl .......................... 9
MEGACE ES .............................12
megestrol acetate ....................12
meloxicam ............................... 7
melphalan hcl ..........................11
MENACTRA ..............................31
MENOMUNE-A/C/Y/W-135 .........31
MENTAX..................................37
meprobamate ..........................17
MEPRON .................................11
mercaptopurine .......................12
MERUVAX II W/DILUENT 10 D....31
mesalamine.............................27
mesna ....................................13
MESNEX..................................13
MESTINON ..............................21
MESTINON TIMESPAN ...............21
METADATE CD .........................21
metaxalone .............................22
metformin hcl ..........................23
methadone hcl .......................... 6
METHADONE HCL ...................... 6
methazolamide ........................17
methimazole ...........................26
methocarbamol........................22
methotrexate sodium.......... 12, 30
methyldopa .............................17
METHYLIN ...............................21
methylphenidate hcl .................21
methylprednisolone ..................25
methylprednisolone acetate .......25
methylprednisolone sod succ .....25
metipranolol ............................35
metoclopramide hcl ..................27
metolazone .............................17
metoprolol & hydrochlorothiazide16
metoprolol succinate.................16
metoprolol tartrate ...................16
METROGEL ..............................39
metronidazole..........................11
metronidazole (topical) .............39
metronidazole in nacl ............... 11

metronidazole vaginal............... 29
mexiletine hcl .......................... 15
MIACALCIN ............................. 24
MICARDIS............................... 15
MICARDIS HCT ........................ 14
midodrine hcl .......................... 17
MIGERGOT.............................. 21
minocycline hcl ..........................8
minoxidil................................. 17
mirtazapine............................. 19
misoprostol ............................. 28
mitomycin............................... 12
MITOXANTRONE HCL ................ 13
M-M-R II W/DILUENT 10 DOS .... 31
moexipril hcl ........................... 14
moexipril-hydrochlorothiazide .... 14
mometasone furoate ................ 38
morphine sulfate........................6
MORPHINE SULFATE...................6
MOZOBIL ................................ 29
MULTAQ ................................. 15
mupirocin ............................... 37
MUSTARGEN ........................... 11
MYCOBUTIN ............................ 10
mycophenolate mofetil.............. 30
MYFORTIC............................... 30
MYOZYME ............................... 24
N
nabumetone..............................7
nadolol ................................... 16
nafcillin sodium..........................8
NAGLAZYME ............................ 24
naloxone hcl............................ 22
naltrexone hcl ......................... 22
NAMENDA ............................... 19
NAMENDA TITRATION PAK ........ 19
naphazoline hcl........................ 35
naproxen ..................................7
naproxen sodium .......................7
NARDIL .................................. 19
NASACORT AQ......................... 36
NASONEX ............................... 36
NATACYN ................................ 34
nateglinide .............................. 23
NAVANE ................................. 20
NEEDLES, INSULIN DISP.,
48
SAFETY...................................23
nefazodone hcl ........................19
neomycin sulfate....................... 8
neomycin-bacitracin zn-polymyxin
.............................................34
neomycin-polymy-dexameth......33
neomycin-polymy-gramicid........34
neomycin-polymyxin-hc (ophth) .33
neomycin-polymyxin-hc (otic) ....39
NEORAL ..................................30
NEPHRAMINE...........................32
NEUPOGEN..............................29
NEURONTIN ............................18
NEXAVAR ................................13
NEXIUM ..................................28
NEXIUM I.V. ............................28
NIASPAN.................................15
NICOTROL INHALER .................22
NICOTROL NS..........................22
nifedipine ................................16
NILANDRON ............................12
NIMODIPINE............................16
nisoldipine...............................16
NITRO-DUR .............................17
nitrofurantoin macrocrystal........11
nitrofurantoin monohyd macro ...11
nitroglycerin ............................17
NITROLINGUAL PUMPSPRAY ......17
NITROSTAT .............................17
NORDITROPIN CARTRIDGE ........25
NORDITROPIN NORDIFLEX PEN..26
norethindrone acetate...............26
NORMOSOL-R ..........................33
NORPACE CR ...........................15
nortriptyline hcl .......................19
NORVIR ................................... 9
NOVOLIN 70/30 .......................23
NOVOLIN 70/30 INNOLET..........23
NOVOLIN N .............................23
NOVOLIN N INNOLET ................23
NOVOLIN R .............................23
NOVOLOG ...............................23
NOVOLOG FLEXPEN ..................23
NOVOLOG MIX 70/30................23
NOVOLOG MIX 70/30 PREFILL....23
NOXAFIL .................................. 9
nystatin ................................... 9
nystatin (mouth-throat) ............39
nystatin (topical) ..................... 37

O
octreotide acetate .................... 26
OCTREOTIDE ACETATE ............. 26
ofloxacin (ophth) ..................... 34
ofloxacin (otic) ........................ 39
omeprazole ............................. 28
ONCASPAR.............................. 13
ondansetron............................ 27
ondansetron hcl ....................... 27
ONGLYZA................................ 23
ONTAK ................................... 12
OPANA ER.................................6
ORACEA ................................. 39
ORAP ..................................... 20
ORFADIN ................................ 24
orphenadrine citrate ................. 22
ORPHENADRINE COMPOUND DS 22
orphenadrine w/ aspirin & caff ... 22
OXALIPLATIN .......................... 13
oxandrolone ............................ 22
OXANDROLONE ....................... 22
oxaprozin..................................7
oxcarbazepine ......................... 18
OXISTAT................................. 37
OXSORALEN ULTRA .................. 38
oxybutynin chloride .................. 29
oxycodone hcl ...........................6
oxycodone w/ acetaminophen ......6
oxycodone w/ aspirin..................6
OXYCONTIN ..............................6
OXYTROL ................................ 29
P
PACERONE .............................. 15
paclitaxel ................................ 12
PANRETIN ............................... 39
PANTOPRAZOLE SODIUM .......... 28
parenteral electrolytes .............. 31
paromomycin sulfate ..................8
paroxetine hcl ......................... 19
PASER .................................... 10
PATADAY ................................ 34
PATANOL ................................ 34
PEDIARIX ............................... 31
PEDVAX HIB............................ 31
peg 3350-kcl-sod bicarb-sod
49
chloride-sod sulfate ..................28

peg 3350-potassium chloride-sod
bicarbonate-sod chloride ...........28
PEGANONE..............................18
PEGASYS ................................30
PEG-INTRON ...........................30
PEG-INTRON REDIPEN ..............30
penicillin g potassium ................ 8
PENICILLIN G PROCAINE............ 8
penicillin v potassium................. 8
PENTASA ................................27
pentostatin..............................12
pentoxifylline...........................29
PEPCID ...................................27
perindopril erbumine ................14
permethrin ..............................39
perphenazine...........................20
perphenazine-amitriptyline ........22
phenytoin ...............................18
phenytoin sodium.....................18
phenytoin sodium extended .......18
PHOSLO..................................26
PHOTOFRIN.............................13
pilocarpine hcl (oral).................39
PILOPINE HS ...........................35
pindolol ..................................16
piperacillin sodium-tazobactam
sodium .................................... 8
piroxicam................................. 7
PLASMA-LYTE 56......................33
PLASMA-LYTE A .......................33
PLASMA-LYTE-148....................33
PLASMA-LYTE-148/D5W ............33
PLASMA-LYTE-56/D5W..............33
PLAVIX ...................................29
podofilox.................................39
polyethylene glycol 3350 ...........28
polymyxin b-trimethoprim .........34
potassium chloride ............. 31, 33
POTASSIUM CHLORIDE 0.15% ...33
POTASSIUM CHLORIDE 0.3%/ ...33
potassium chloride in d5w lactated
ringers....................................33
potassium chloride in dextrose ...33
potassium chloride in dextrose &
sodium chloride .......................33
potassium chloride in nacl .........33
potassium chloride
microencapsulated crystals cr .... 31

potassium citrate (alkalinizer) .... 28
pramipexole dihydrochloride ...... 19
PRANDIN ................................ 24
pravastatin sodium................... 15
prazosin hcl............................. 14
PRED MILD ............................. 34
prednisolone ........................... 25
prednisolone acetate (ophth) ..... 34
PREDNISOLONE SODIUM PHOSP 34
prednisolone sodium phosphate . 25
prednisone .............................. 25
PREDNISONE INTENSOL ........... 25
PREFEST................................. 24
PREMARIN .............................. 25
PREMARIN W/APPLICATOR ........ 25
PREMASOL .............................. 32
PREMPHASE ............................ 25
PREMPRO................................ 25
prenatal without a vit w/ iron
carbonyl-folic acid .................... 33
PREVPAC ................................ 28
PREZISTA .................................9
PRIFTIN.................................. 10
PRIMAXIN I.M.......................... 11
PRIMAXIN IV ........................... 11
primidone ............................... 18
PRISTIQ ................................. 19
PROAIR HFA ............................ 36
probenecid ................................6
PROCALAMINE ......................... 32
prochlorperazine ...................... 27
prochlorperazine edisylate......... 27
prochlorperazine maleate .......... 27
PROCRIT................................. 29
PROGLYCEM ............................ 25
PROGRAF................................ 30
PROLEUKIN ............................. 12
PROMACTA.............................. 29
promethazine hcl ..................... 27
PROMETRIUM .......................... 26
propafenone hcl ....................... 15
proparacaine hcl ...................... 35
propranolol hcl ........................ 16
propylthiouracil........................ 26
PROQUAD ............................... 31
PROSOL.................................. 32
PROTOPIC............................... 38
50
protriptyline hcl .......................19

PROVENTIL HFA .......................36
PROVIGIL................................22
PULMICORT FLEXHALER ...... 36, 37
PULMOZYME ............................36
pyrazinamide...........................10
pyridostigmine bromide.............21
Q
QUALAQUIN ............................. 9
quinapril hcl ............................14
quinapril-hydrochlorothiazide .....14
quinidine gluconate ..................15
quinidine sulfate ......................15
QUIXIN...................................34
QVAR .....................................36
RIBASPHERE ........................... 10
RIBAVIRIN .............................. 10
ribavirin (hepatitis c) ................ 10
rifampin.................................. 10
RILUTEK ................................. 21
rimantadine hydrochloride......... 10
ringer's................................... 33
RISPERDAL CONSTA................. 20
risperidone.............................. 20
RITALIN LA ............................. 21
RITUXAN ................................ 12
ROBAXIN ................................ 22
ropinirole hydrochloride ............ 19
ROTATEQ................................ 31
ROXICET...................................6
RYTHMOL SR ........................... 15
R
RABAVERT ..............................31
ramipril...................................14
RANEXA ..................................17
ranitidine hcl ...........................27
RAPAMUNE..............................30
REBETOL.................................10
REBIF .....................................21
REBIF TITRATION PACK ............22
RECOMBIVAX HB......................31
REGONOL ...............................21
REGRANEX ..............................39
RELENZA DISKHALER ...............10
RELION R................................24
RELISTOR ...............................28
RELPAX...................................21
REMICADE ..............................30
RENAGEL ................................26
RENAMIN ................................32
RENVELA ................................26
REQUIP XL ..............................19
RESCRIPTOR ............................ 9
RESTASIS ...............................35
RETIN-A MICRO .......................37
RETROVIR IV INFUSION ............. 9
REVATIO.................................17
REVLIMID ...............................30
REYATAZ.................................. 9
RHEUMATREX ..........................30
RHINOCORT AQUA ...................36
RIBAPAK .................................10
S
SABRIL................................... 18
SAIZEN .................................. 26
SAIZEN CLICK.EASY ................. 26
SANCTURA XR ......................... 29
SANCUSO ............................... 27
SANDIMMUNE ......................... 30
SANDOSTATIN LAR DEPOT ........ 26
SANTYL .................................. 39
SAPHRIS................................. 20
SAVELLA................................. 21
SAVELLA TITRATION PACK ........ 21
selegiline hcl ........................... 20
selenium sulfide....................... 38
SELZENTRY ...............................9
SENSIPAR ............................... 24
SEREVENT DISKUS .................. 36
SEROMYCIN ............................ 10
SEROQUEL .............................. 20
SEROQUEL XR ......................... 20
sertraline hcl ........................... 19
silver sulfadiazine .................... 37
SIMCOR.................................. 15
simvastatin ............................. 15
SINGULAIR ............................. 36
sodium chloride ................. 31, 33
sodium chloride (gu irrigant) ..... 39
sodium fluoride........................ 31
sodium polystyrene sulfonate .... 24
SOLARAZE .............................. 37
SOLU-CORTEF ......................... 25
51
SOMATULINE DEPOT ................26

SOMAVERT..............................26
SORIATANE .............................38
sotalol hcl ...............................15
SPIRIVA HANDIHALER ..............35
spironolactone .........................14
spironolactone &
SPORANOX............................... 9
SPRYCEL .................................13
STALEVO 100 ..........................20
STALEVO 125 ..........................20
STALEVO 150 ..........................20
STALEVO 200 ..........................20
STALEVO 50 ............................20
STALEVO 75 ............................20
stavudine ................................. 9
STELARA.................................38
STRATTERA .............................21
streptomycin sulfate .................. 8
SUBOXONE .............................22
SUCRAID ................................24
sucralfate................................28
sulfacetamide sodium (acne) .....37
sulfacetamide sodium (ophth) ....34
sulfacetamide sod-prednisolone..33
SULFADIAZINE ......................... 8
sulfamethoxazole-trimethoprim ..11
sulfasalazine............................27
sulindac ................................... 7
sumatriptan succinate...............21
SUPRAX ................................... 8
SURMONTIL ............................19
SUSTIVA .................................. 9
SUTENT ..................................13
SYMBICORT.............................37
SYMLIN...................................24
SYMLINPEN 120 .......................24
SYMLINPEN 60.........................24
SYNAREL ................................24
SYNTHROID ............................26
SYPRINE .................................24
T
TABLOID.................................12
tacrolimus ...............................30
TACROLIMUS...........................30
TAMIFLU .................................10
tamoxifen citrate ..................... 12

tamsulosin hcl ......................... 28
TARCEVA ................................ 13
TARGRETIN ....................... 13, 39
TARKA.................................... 14
TASIGNA ................................ 13
TAXOTERE .............................. 12
TEGRETOL-XR ......................... 18
TEKTURNA .............................. 16
TEKTURNA HCT ....................... 16
terazosin hcl............................ 14
terbinafine hcl ...........................9
terbutaline sulfate .................... 36
terconazole vaginal .................. 29
TESTIM .................................. 22
testosterone cypionate.............. 22
testosterone enanthate ............. 22
TETANUS TOXOID ADSORBED ... 31
TETANUS/DIPHTHERIA TOXOID . 31
tetracycline hcl ..........................8
TEVETEN ................................ 15
TEVETEN HCT .......................... 14
TEV-TROPIN ............................ 26
THALITONE ............................. 17
THALOMID .............................. 30
THEO-24................................. 37
theophylline ............................ 37
THIOLA .................................. 28
thioridazine hcl ........................ 20
thiothixene.............................. 20
ticlopidine hcl .......................... 29
TIKOSYN ................................ 15
timolol maleate (ophth) ............ 35
TINDAMAX .............................. 11
tizanidine hcl ........................... 22
TOBI ...................................... 36
TOBRADEX.............................. 33
tobramycin sulfate .....................8
tobramycin sulfate (ophth) ........ 34
tobramycin-dexamethasone ...... 33
TOBREX.................................. 34
tolmetin sodium.........................7
topiramate .............................. 18
torsemide ............................... 17
TORSEMIDE ............................ 17
TOVIAZ .................................. 29
TRACLEER............................... 17
tramadol hcl..............................6
52
tramadol-acetaminophen............ 6
trandolapril .............................14
trandolapril-verapamil hcl..........14
TRANSDERM-SCOP ...................27
tranylcypromine sulfate.............19
TRAVASOL ..............................32
TRAVATAN Z ...........................35
trazodone hcl...........................19
TREANDA ................................11
TRECATOR ..............................10
TRELSTAR DEPOT MIXJECT ........13
TRELSTAR LA MIXJECT..............13
tretinoin..................................37
TRETINOIN..............................13
triamcinolone acetonide (mouth) 39
triamcinolone acetonide (topical) 38
triamterene & hydrochlorothiazide
.............................................17
TRICOR ..................................15
trifluoperazine hcl ....................20
trifluridine ...............................34
trihexyphenidyl hcl ...................20
TRIHIBIT ................................31
TRILIPIX .................................15
trimethobenzamide hcl..............27
trimethoprim ...........................11
TRIPEDIA ................................31
TRISENOX...............................13
TRIZIVIR ................................. 9
TROPHAMINE...........................32
TRUVADA ................................. 9
TWINRIX.................................31
TYGACIL .................................11
TYKERB ..................................13
TYPHIM VI...............................31
TYZEKA ..................................10
TYZINE ...................................36
TYZINE PEDIATRIC NASAL DR....36
U
ULORIC ................................... 6
UROXATRAL ............................28
ursodiol ..................................28
V
VAGIFEM ................................25
valacyclovir hcl ........................10
VALCYTE .................................10
valproate sodium ..................... 18

valproic acid............................ 18
VALTURNA .............................. 14
VANCOCIN HCL........................ 11
vancomycin hcl ........................ 11
VANCOMYCIN HCL ISO-OSMOTI . 11
VAQTA ................................... 31
VARIVAX ................................ 31
VELCADE ................................ 12
venlafaxine hcl ........................ 19
verapamil hcl .......................... 16
VESICARE ............................... 29
VFEND......................................9
VFEND IV..................................9
VIDAZA .................................. 12
VIDEX ......................................9
VIGAMOX................................ 34
VIMPAT .................................. 18
VINBLASTINE SULFATE ............. 12
vincristine sulfate..................... 12
vinorelbine tartrate .................. 12
VIRACEPT ............................... 10
VIRAMUNE .............................. 10
VIREAD .................................. 10
VISICOL ................................. 28
VIVELLE-DOT .......................... 25
VIVOTIF BERNA ....................... 31
VOLTAREN ................................7
VOTRIENT............................... 13
VPRIV .................................... 24
VYTORIN ................................ 15
W
warfarin sodium....................... 29
WELCHOL ............................... 15
X
XALATAN ................................ 35
XENAZINE............................... 21
XIBROM.................................. 34
XOLAIR .................................. 36
XOPENEX ................................ 36
XOPENEX HFA ......................... 36
XYREM ................................... 22
XYZAL .................................... 35
Y
YF-VAX ................................... 31
53
Z
zaleplon ..................................21
ZAVESCA ................................24
ZEGERID.................................28
ZEMPLAR ................................33
ZENPEP ..................................28
ZETIA .....................................15
ZIAGEN ..................................10
zidovudine ..............................10
ZOLINZA.................................13
zolpidem tartrate .....................21
ZOMETA ................................. 24
ZOMIG ................................... 21
ZOMIG ZMT ............................ 21
ZONALON ............................... 37
zonisamide.............................. 18
ZOSTAVAX .............................. 31
ZOVIRAX ................................ 38
ZYMAR ................................... 34
ZYPREXA ................................ 20
ZYPREXA ZYDIS....................... 20
ZYVOX ................................... 11
54

Fidelis Care 2011 Formulary (List of Covered Drugs)

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Fidelis Care 2011 Formulary (List of Covered Drugs)

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Fidelis Care

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Fidelis Care is a Medicare Advantage organization with a Medicare contract.

H3328 FC 10106 File & Use 09082010

What is the Fidelis Care Formulary?

Can the Formulary change?

What are generic drugs?

Are there any restrictions on my coverage?

How do I request an exception to the Fidelis Care Formulary?

What do I do before I can talk to my doctor about changing my drugs or requesting an

For more information

Fidelis Cares Formulary

QL (60 tabs / 25 days)

NARCOTIC ANALGESICS, CII

ANTIMITOTIC, VINCA ALKALOIDS

BIOLOGIC RESPONSE MODIFIERS

HORMONAL ANTINEOPLASTIC AGENTS

PLATINUM COORDINATION COMPLEX

ALDOSTERONE RECEPTOR ANTAGONISTS

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS

ANGIOTENSIN II RECEPTOR ANTAGONISTS

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS

CALCIUM CHANNEL BLOCKERS

DIRECT RENIN INHIBITORS

PULMONARY ARTERIAL HYPERTENSION

CENTRAL NERVOUS SYSTEM

QL (1080 caps / 25 days);

QL (120 caps / 25 days)

ATTENTION DEFICIT HYPERACTIVITY DISORDER

QL (180 tabs / year)

QL (18 tabs / 25 days)

(12 tabs / 25 days)

MULTIPLE SCLEROSIS AGENTS

MUSCULOSKELETAL THERAPY AGENTS

ENDOCRINE AND METABOLIC

CALCIUM RECEPTOR ANTAGONISTS

GLUCOSE ELEVATING AGENTS

HUMAN GROWTH HORMONES

PHOSPHATE BINDER AGENTS

SELECTIVE ESTROGEN RECEPTOR MODULATORS

QL (60 caps/25 days), PA

INFLAMMATORY BOWEL DISEASE

PROTON PUMP INHIBITOR/ANTI-INFECTIVE COMBINATIONS

PROTON PUMP INHIBITORS

QL (90 days per year)

HEMATOPOIETIC GROWTH FACTORS

PLATELET AGGREGATION INHIBITORS

ipratropium bromide (nasal)

QL (30 caps / 25 days)

B/D, QL (100 bags / 25

LEUKOTRIENE RECEPTOR ANTAGONISTS

MAST CELL STABILIZERS

B/D, QL (120 bags / 25

DERMATOLOGY, ACTINIC KERATOSIS

DERMATOLOGY, LOCAL ANESTHETICS

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE

DERMATOLOGY, SCABICIDES AND PEDICULIDES

DERMATOLOGY, WOUND CARE AGENTS

benazepril hcl .......................... 14

enalapril maleate &

fat emulsion ............................32

FREAMINE III 3%..................... 32